Why 5 A Day Fell Short And Alternative Solutions in the form of Community Supported Agriculture– Jacquelyn Murphy

Fruits and vegetables are an important part of everyone’s diet. They provide vitamins, fiber, and few calories, which are all things anyone, especially most Americans, could benefit from. With these things in mind, the National Cancer Institute and the Produce for Better Health Foundation teamed up to found a nutrition program, entitled 5 A Day for Better Health, in 1991 (4). The 5 A Day program very simply encourages people to eat five servings of fruits and vegetables every day as part of a low-fat, high-fiber diet, marking packages of acceptable fruits and vegetables with the small trademark symbol (2). On the Center for Disease Control and Prevention Website, there are recipe ideas to incorporate servings of fruits and vegetables into meals as well as tips on how to reach the five servings, such as having fruit or vegetables for in-between meal snacks. In 1991, when the program first began, and in 1997 after six years of spreading the “5 A Day” message and pouring millions of tax dollars into raising awareness on this critical nutrition issue, there was no significant difference in fruit and vegetable consumption after researchers adjusted for demographic shifts (4). The 5 A Day program is flawed in that it is based on the Health Belief Model and thus the assumption that people act rationally, it lacks consideration for environmental factors, and it advertised poorly. These flaws could account for part, or all, of the lack of response after millions of dollars were spent on increasing awareness of the 5 A Day for Better Health program.
Based on assumptions of Health Belief Model.
The 5 A Day program is based entirely on the idea that if people are educated about what actions they should take to optimize their health, in this case eat at least five servings of fruits and vegetables daily, then they will do it. Like many public health interventions based on the Health Belief Model, it is limited in various ways and assumes a few different things. Many individual level models assume that people act rationally and plan their behavior. The Health Belief Model is no different. In general, the Health Belief Model is based on increasing perceived susceptibility or perceived severity, or both, of the consequences of performing or not performing a certain action (3). From here, people determine the perceived benefits of adhering to guidelines set by the intervention, as well as barriers preventing them from following the guidelines of the intervention outlined by the Health Belief Model. Finally, they come to a conclusion and determine their intention, which they then carry out through their behavior, which is both planned and rational (3).
Specifically, the limitations and assumptions of the Health Belief Model come into play in a few different ways in the 5 A Day nutrition campaign. First, this campaign gives people information about what they should be doing, eating five servings of fruits and vegetables per day. From there, it assumes they will change their behavior to eating five or more servings of fruits and vegetables just because they know it is beneficial to their overall health. The campaign does not take into consideration that people oftentimes do not care about their health, or care about it enough to give up their unhealthy, but perhaps tastier, habits, such as eating a cookie instead of an apple. People value their health as much as they do not want to be sick or feel poorly, but many people do not think about their actions’ impact on their long term health. They usually invest their thought in other things, such as appearing attractive or being well-liked, rather than spending their time thinking about their slightly increased chances of certain types of cancer years down the road due to poor nutritional choices.
Secondly, and somewhat deviating from the limitations of the Health Belief Model, this campaign does little to raise people’s perceived susceptibility or severity of the consequences of not eating five servings of fruits and vegetables, which is a trademark of interventions based on the Health Belief Model. If the campaign was more strictly based on the Health Belief Model, it would incorporate more information about the negative repercussions of their lack of eating at least five servings of fruits and vegetables in order to scare people into action. However, this campaign tries to get people to eat five servings of produce without the aspect of increasing people’s perceived susceptibility or severity of potential negative consequences.
Thirdly, since it assumes that people’s behavior is rational, it obviously does not capitalize on the ways in which the behavior of most people is irrational. There are three main facets to irrational behavior, as discussed in this lecture January 29, 2009. The first is that people have expectations of how things should be, and their experiences impact their expectations. The second is that people enjoy owning things and have an aversion to losing the things they own. The third aspect of irrational behavior is that people generally do not have as much self-control as they think they do. Rather, they are mostly lazy procrastinators. The 5 A Day campaign mostly disregards the second of the three features of irrationality in that it did not take into account the strength of people’s habits. They own their unhealthy eating habits, and they will only relinquish these unhealthy habits and practice self control, another feature of irrational behavior not taken into account by the 5 A Day campaign, if they think they will be rewarded with a result that they deem to be worthy of their sacrifice and effort to change their behavior.
Lacks consideration for environmental factors.
Another reason that there was such an insignificant change in the amount of fruits and vegetables people ate before and after the implementation of the 5 A Day nutrition campaign is the lack of consideration for environmental factors. Barriers to consuming the recommended five servings of fruits and vegetables, according to a survey of single mothers included cost, lack of availability, time and effort required to prepare produce, a preference for other foods instead and habit (6). Some of these environmental factors were discussed in the experiments performed during the first seminar meetings on January 22, 2009. Groups went to grocery stores in Roxbury and the South End, two different neighborhoods near the Boston University Medical Campus. The groups that went to the South End, the wealthier of the two neighborhoods, found plenty of full-sized grocery stores, such as Trader Joe’s and Whole Foods, which contained many varieties of fruits and vegetables, usually including a lot of organic produce as well. On the contrary, groups that went in search of produce in Roxbury could only find small and overpriced convenience stores in their designated neighborhood, which usually contained a very small selection of fruits and vegetables which did not look appetizing, especially relative to the produce from the South End grocery stores. Therefore, the residents of Roxbury and other similar neighborhoods had to put in a larger time and effort to get the same quality of food which residents of the South End and other comparable neighborhoods can get quickly and easily.
Aside from availability of produce in their neighborhoods, students in the seminar groups also pointed out the safety of the two different neighborhoods. Roxbury has a much higher crime rate than the South End, adding an element of danger to getting groceries at night after people get out of work, which is when most people have time to do so. Since produce spoils faster than less nutritious, packaged snacks, such as cookies or crackers, it requires more frequent trips to the store. The lack of safety of a neighborhood makes keeping fresh produce available in the house even more difficult than it would be if the grocery store were closer or the trip there less risky.
Finally, amongst a variety of other environmental factors that should have been taken into account by the 5 A Day campaign, financial cost was not considered. As is easily observed in any grocery store, the fresh produce that the 5 A Day campaign strongly encourages is much more expensive than other foods that are perhaps less nutritious but would fill stomachs when parents’ main concern is making sure their children are all able to have dinner. The campaign did not enlist the government to subsidize the cost of produce in any way or perhaps try to organize farmers to sell their produce directly to the customer at farmer’s markets, which would be beneficial to both the farmer and the customer in terms of cost.
In short, the 5 A Day campaign was set up as if people made their decisions in a vacuum, but they do not. They have to think about availability of produce, their own safety when they are en route to buy food for the family and how they will bear the financial costs, among many other environmental factors which are likely too numerous to list here.
Poor advertising methods and media.
Lastly, the methods of advertising employed by the 5 A Day campaign were another shortcoming of the national nutrition intervention. They did not utilize basic principles of communications theory or the idea of agenda setting within the theory. Agenda setting within Communications Theory notes that the target audience, in this case people who are buying food for their families or deciding what to eat when faced with different options, must view the information as important enough to really hear the message and act on it (1). Being bombarded on a daily basis with countless messages about what is best for a healthy lifestyle, it is difficult to distinguish the useful information from the useless. If people do not care, they will not spend the extra money on fresh produce or decide to eat that instead of tastier, less nutritious foods. Creating a message the person in the situation can relate to is the primary focus of agenda setting because the goal is to dramatize the issue and get the audience to care about the issue enough to act, since they view it as important (1). Advertising created with this in mind, and using basic principles of agenda-setting theory, such as dramatizing an issue to make it important to people, would be most effective.
However, the main method of advertising used by the 5 A Day campaign was to put a logo on the sides of packaging which contained acceptable servings of fruits and vegetables and to distribute informative pamphlets in the offices of primary care physicians. Not only is this foolish since most people already know what counts as a fruit or vegetable, but this medium, which the 5 A Day campaign chose to use, does not reach the target audience. People who are purchasing products with this logo on them are already attempting to reach their five servings, or at least already have enough information to know that fruits and vegetables are worth their money. The target audience for this message should include the large portion of the population who drastically fall short of the five servings per day mark, which tends to be adults with less education, lower income and uncertainty about whether or not they will consistently have food in the near future (6). This part of the population is either not at the grocery store for reasons mentioned before, or they are not in that aisle, examining the produce closely enough to see the small 5 A Day logo encouraging them to buy that product. They are likely deciding which foods to buy based on the amount of money they have and possibly also what will keep their family feeling satisfied longest. A second reason that this medium is ineffective is that it in no way dramatizes the issue, which would increase the likelihood that people would care enough to pay attention and change their behavior, which showed by a self-reported survey that most people do not get five servings of fruits and vegetables daily (5). It simply provides guidance to the products condoned by 5 A Day, should the person already have established that habit. There was a small improvement with the information in the doctor’s offices, since they actually provided reasons why the reader should try to incorporate more produce instead of simply putting a logo on a package and expecting a drastic improvement. The pamphlets and the information about this program on the Center for Disease Control and Prevention website provide information from studies that found five servings to be where they saw lowered rates of many chronic illnesses such as cancer and obesity, which is where this campaign incorporates tenants of the Health Belief Model, as outlined above.
In conclusion, the 5 A Day campaign tried to change the nutrition of a nation by raising awareness, but awareness does not change behavior. The first flaw of the 5 A Day campaign is assuming that people plan their behavior, which is always rational, and do what they intend to do. As extensively studied, behavior is oftentimes irrational, a fact disregarded by the 5 A Day for Better Health Program. Secondly, the 5 A Day campaign assumes that behavior takes place in a vacuum, and it does not consider various environmental factors that impact people’s food choices, such as the high relative cost of fresh fruits and vegetables, the lack of access people in neighborhoods with a low average socioeconomic status have to grocery stores, and the safety of these neighborhoods for them to get to the grocery store in the first place. Lastly, a lack of consideration for how to deliver the message, by picking ineffective media to deliver the message through, and a lack of dramatizing the issue of incorporating enough produce into a healthy diet have both lead the general public to be largely uninformed or unengaged – as uninformed or unengaged in 1997 after the intervention as they were in 1991.

Since the vast majority of the population falls short of the goal of five servings of fruits and vegetables every day, other groups had to develop ways, separate from the government’s 5 A Day for Better Health program, that those most in need could have access to produce. Four factors have been found to increase fruit and vegetable consumption, including point-of-purchase (POP) information; reduced prices and coupons; increased availability, variety, and convenience; and promotion and advertising (11). Instead of asking the government to subsidize the cost of fresh produce they were encouraging the citizens to eat, in turn further increasing many of the deficits at the state and federal level, Community Supported Agriculture was developed. Little known to many people, Community Supported Agriculture is a grassroots movement that puts produce within reach of people of all socioeconomic backgrounds. Community Supported Agriculture is an intervention that addresses the 5 A Day campaign’s poor advertising, lack of consideration for environmental factors and assumption that people hold their health as one of their core values. In addition, Community Supported Agriculture offers both a wide variety of produce and lower costs, two factors shown to directly increase fruit and vegetable consumption.
First, an explanation of Community Supported Agriculture is necessary, because despite them being quite widespread, not everyone has heard of, or is knowledgeable about, such programs. These farms can come about in a number of ways. Farmers sign up their farms with organizations, or they simply designate their farm as Community Supported Agriculture land without the organization (8). Another way is for a city or town to own land and a group of committed individuals take responsibility for the land each season. Either way, they sell shares, also known as subscriptions or memberships, to people who do not own a farm, known as the consumers. In exchange for a flat rate that consumers pay to cover the costs of growing materials and supplies on a per season basis, they receive a box of fresh, locally grown produce, usually vegetables. They can pay more or less depending on the size box and variety of produce within the box. Additionally, most Community Supported Agriculture farmers will accept food stamps if that is how the family would normally pay for produce, were they to purchase the food in a grocery store. Families may also choose to trade labor for food if they do not have food stamps or the money to pay up front, which is a problem for many families (9). Especially if they have been unemployed or are consistently living beyond their means even as they subsist in unpleasant living conditions, the “labor for food” option offers membership to those who are struggling most. Finally, these memberships are not for sale to those strictly adjacent to the farm. On the contrary, the farmers usually have several drop off locations to reach a wider customer base (8).
More effective advertising.
Community Supported Agriculture does not advertise or communicate with the public as a typical public health campaign is expected to. They do not have commercials on television or the radio, but they use what has been the most effective method of advertising for years: word of mouth. Before the growing season begins, farmers typically try to sign people up for memberships in order to get their cash flow jumpstarted, as they usually have been without a reliable income during the winter. Satisfied consumers will likely spread the word about where they got their produce, and encouragement from a trusted friend or family member is usually most successful in convincing someone that buying something, in this case a membership, or spending their time doing something, such as helping on the farm in exchange for produce, is worthwhile. Additionally, people in the Community Supported Agriculture would be looking for people to share the costs, monetary or labor, which would lead to them recruiting people they trust to follow through on either or both accounts.
The whole premise of Community Supported Agriculture is to keep costs down to everyone, so a mainstream, widespread advertising campaign would, in itself, be contradictory to the message of the Community Supported Agriculture. Instead of spending their time trying to convince people that they should be eating more fresh vegetables, they provide it for those that want it and are willing to buy or work for it. Also, due to hearing about the Community Supported Agriculture through friends, it makes sense that skepticism would be reduced, which is oftentimes high when people are asked to change something about their lifestyle by the government.
Availability of nutritious foods has been shown to have a positive association with their consumption, therefore Community Supported Agriculture makes this food truly available to consumers, unlike the small corner stores typical in supermarket desserts which contain a very small, very expensive produce selection (7).
If Community Supported Agriculture were to improve or expand upon this method of advertising, they should put their information where the largest amount of their target audience will be reached. Needless to say, this is not on the label of a package of produce, as the 5 A Day campaign is currently advertising. The point of such a campaign is to get the potential consumer to walk over to that section of the store and pick up the produce in the first place. Perhaps in community health clinics, which are the main, or only, source of medical care for those without health insurance, informational brochures could explain what Community Supported Agriculture is and the benefits it offers as well as and provide a phone number to call or person to contact if they were interested in getting a membership to that particular farm. Also, in community centers, such as the Boys and Girls Club, a large percentage of the attendees there would benefit from knowing of a Community Supported Agriculture farm, so more information could be distributed at similar places.
Consideration for peoples’ varying environments.
Community Supported Agriculture not only takes environmental factors into consideration, on the contrary it was seemingly founded on the principle of providing produce for those who have difficulty accessing it. Given the way environments are currently, with supermarket desserts, as witnessed in Roxbury, Massachusetts in the seminar exercise, not only is fresh produce expensive once people get to the grocery store, but for residents of neighborhoods similar to Roxbury, it is a huge time investment to take a trip to the grocery store. The drop off locations that many Community Supported Agriculture farms have organized still require the consumers to pick up the produce as they would in a grocery store, but the drastically reduced cost alleviates one of the major stressors people encounter when buying fresh produce. Of course, there are limitations to this idea, especially if the potential consumer is not located near the farm itself or near to a drop off location and does not have a car to get there. However, on the whole, the two major environmental factors which the 5 A Day campaign ignored were the monetary access and geographic proximity to a store with a decent selection of fresh produce. Additionally, the logistical limitations will always be difficult to get around, and the farmers and consumers must work together to set up the most convenient place for as many people as they are able.
As previously mentioned, for people who cannot pay for the vegetables up front, they can work in exchange for a membership to the Community Supported Agriculture. This is another level of alleviating the financial burden and offering inclusiveness, since it provides a way for people who are unemployed and underemployed to also have a membership and access to healthy food. For many, being unemployed usually means an absence of all nutritious or extra food except the bare minimum, in quantity and quality, families can afford.
Not based on Health Belief Model assumptions.
Unlike the 5 A Day for Better Health campaign, community supported agriculture is not based on the major assumption that people behave rationally. This idea does not try to convince people, as 5 A Day does, to eat five servings of fruits and vegetables because it is good for them and then they will be healthier and possibly have reduced cancer risk years from now. It simply offers the option of eating healthier at a lower cost.
Additionally, much like the sticktoit.com website discussed in lecture, it does involve an initial monetary payment to the farm, which people do not get back if they do not pick up their food every week. When people put their money on the line, they are more likely to follow through on their actions, and certainly they would be more motivated to go get food they have already paid for.
However, there would most likely be some people who are not paying for the produce, but rather working in exchange for the box of fruits and vegetables. These individuals are driven to stick with eating the produce because they have invested time into the health and growth of the vegetables. Often, they have worked very hard every week and feel bonded to their produce or they know how much work went into producing the vegetables so they are less likely to waste them by letting them go bad or not retrieving them from the drop off stations.
Additionally, children and young people can, and should, perhaps, get involved in the Community Supported Agriculture. Studies have shown that in regards to young people, they are most likely to consume healthier foods when they choose the foods instead of being told what to eat by their parents or guardians (10). If the children had been in charge of watering the same tomato plant or corn stalk each time the family went to the farm, they would obviously have a sense of pride when the vegetable was ripe and ready to eat. This finding is not surprising, given that one of the main core values children and adolescents hold in high regard, indeed much higher regard than their own health, is their independence, separation and growth from their parents, as seen in the Truth anti-smoking campaign.
In conclusion, Community Supported Agriculture did not begin initially as a cheaper option, but it has grown into a major alternative for those of lower socioeconomic status as it provides produce at lower costs and often closer to their homes. Geography and monetary cost often prohibit their access to the government-recommended five servings of fruits and vegetables every day, but when the 5 A Day for Better Health campaign made that recommendation, they should have researched what actually gets people to eat more fruits and vegetables. Unlike that campaign, Community Supported Agriculture is based on assumptions shown to hold true about people’s behavior, that they do not care about their health but other things such as money and independence, addresses environmental factors such as making produce geographically and cost available, and advertising itself through word of mouth of previous satisfied consumers. In all these ways, Community Supported Agriculture is a better intervention than the 5 A Day for Better Health campaign.

REFERENCES
1. Edberg, M. (pp. 35-47) In: Edberg, M., ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
2. Heimendinger J, VanDuyn MA, Chapelsky D, Foerster S, Stables G. The National 5 A Day for Better Health Program: A Large-Scale Nutrition Intervention. Journal of Public Health Management and Practice 1996; 2 (2).
3. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
4. Stables G, Subar A, Patterson B, Dodd K, Heimendinger J, VanDuyn MA, Nebeling L. Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association 2002; 102 (6): 809-816.
5. Thompson B, Demark-Wahnefried W, Taylor G, McClelland J, Stables G, Havas S, Feng, Z, Topor M, Heimendinger J, Reynolds K, Cohen N. Baseline fruit and vegetable intake among adults in seven 5 A Day study centers located in diverse geographic areas. Journal of the American Dietetic Association 1999; 99 (10): 1241-1248.
6. Quan T, Salomon J, Nitzke S, Reicks M. Behaviors of low-income mothers related to fruit and vegetable consumption. Journal of the American Dietetic Association 2000; 100 (5): 567-569.
7. Williams DR. Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports 2001; 116:404-416.
8. United States Department of Agriculture. Defining Community Supported Agriculture. http://www.nal.usda.gov/afsic/pubs/Community Supported Agriculture/Community Supported Agriculturedef.shtml
9. National Sustainable Agriculture Information Service. Community Supported Agriculture. http://attra.ncat.org/attra-pub/csa.html
10. Consumer Health Interactive : The Edible Schoolyard. http://www.yourhealthconnection.com/Imagebank/audio_flash/edibleschoolyard.html
11. Glanz K. Yaroch A. Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing, and environmental change. Preventive Medicine 2004; 39 (2): 75-80.

Exercise is Medicine: A Poor Prescription for Physical Activity Promotion – Maureen Harris

Regular physical activity is a critical component of a healthy lifestyle and has a strong role in health maintenance and promotion. Exercise has been shown to reduce the risk of chronic diseases such as cardiovascular disease, diabetes, and cancer; promote quality of life; aid in maintenance of a healthy weight; reduce symptoms of depression; and enhance functional health (1-2).
Despite the manifold benefits of being physically active and risks of being inactive, adherence to the recommended guidelines for activity is remarkably low. The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) recommend 30 minutes of moderate-intensity daily physical activity five days per week (3), and the 2008 Physical Activity Guidelines for Americans released by the Department of Health and Human Services (DHHS) calls for a minimum total accumulation of 150 minutes of moderate physical activity per week (4). Nearly two-thirds of adults in the United States do not meet these recommendations, and a quarter do not exercise at all (5). This has clear and severe public health implications.
The “Exercise is Medicine” Initiative
To address this burning issue, hundreds of small- and large-scale interventions have been developed, yet the problem persists. Many of these programs are based on faulty or tenuous theories or, worse yet, are not based on any framework at all. The Exercise is Medicine (EiM) initiative (6), sponsored by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA) seeks to improve rates of physical activity through encouraging a dialogue about exercise between patients and health care providers. Despite the best intentions, this program, like the others, is fatally weakened by multiple flaws.
The program’s goal is to make physical activity a standard “vital sign.” EiM calls upon health care providers to assess patients’ activity levels at every office visit and to counsel patients on how to become more active. Providers are encouraged to “prescribe” exercise for disease treatment and prevention just as they would prescribe a pharmaceutical as well as to refer patients to fitness professionals just as they would refer to a medical specialist. Additionally, EiM instructs patients to ask their doctors about exercise. The program’s website provides reference materials for providers to facilitate dialogue with patients, and it offers “tool kits” and educational videos for patients to help them initiate an exercise routine. The initiative aims to link exercise with medical treatment and equate exercise with more traditional and familiar modes of treatment, such as pills. It promotes the long term physical health benefits of exercise while presenting limited information on other, more immediate benefits of exercise.
EiM appears to be based on the Health Belief Model (HBM; 7-8), which presents four factors central to an individual’s health behavior motivation: perceived susceptibility (assessment of the likelihood of acquiring disease/condition), perceived severity (assessment of the physical and emotional hardship that may be experienced if the disease/condition is acquired), perceived barriers (assessment of obstacles to perform health behavior, such as cost, access, embarrassment), and perceived benefits (belief that a given action will be efficacious in preventing a negative outcome or minimizing its severity). Each of these factors is considered during decision making and, if the pros of the behavior exceed the cons, the individual will form an intention to engage in the behavior. Intention is assumed to result in behavior. EiM, following the logic of the HBM, emphasizes the risks (i.e., severity) of not exercising, assuming that if people know that they should exercise then they will exercise. Despite its good intentions, EiM’s design is fraught with lack of foresight and faulty logic that severely hinders its potential to improve adherence with national physical activity guidelines. Three fundamental issues with EiM will be discussed: the definition of exercise as a medical treatment, the choice of doctor-patient interactions as the mode of message delivery, and the failure to anticipate barriers.
Definition of Exercise as a Medical Treatment
Defining exercise as medicine is potentially damaging and counterproductive. While the definition is intended to convey the importance of exercise and stress its role in health maintenance, it is more likely to reduce intrinsic motivation to engage in physical activities. Intrinsic motivation is considered to be a desire to participate in an activity for the inherent satisfaction of the activity whereas extrinsic motivation is desire to participate in an activity for a reward distinct from the activity (9). Cognitive evaluation theory (CET; 10-11) proposes that intrinsic motivation relies on social-contextual factors such as perceived choice, autonomy, and enjoyment. Supporting this concept, self-efficacy and perceived satisfaction were shown to predict maintenance of physical activity (13). Presenting exercise as a treatment and as a "doctor's order" implies a lack of choice on the part of the patient. Moreover, by suggesting that exercise is something the patient must do, rather than something the patient wants to do, it undermines inherent enjoyment of, and desire to participate in, the activity (12). Deci and Ryan propose a hierarchy of motivation, including amotivation (no motivation), extrinsic motivation, and intrinsic motivation (11, 14). Extrinsic motivation is broken into four categories which are differentiated by the ratio of external to internal locus of causality. The most external category, external regulation, is associated with compliance and external rewards, whereas the most internal, integrated regulation, is associated with overlap between personal values and the activity. An individual has greater enjoyment of, and greater likelihood of maintaining, an activity when the locus of causality is most internal (9). Thus, intrinsic motivation, or deeply internalized extrinsic motivation, is critical for maintaining a physically active lifestyle. Through its disregard for the components necessary for intrinsic motivation, EiM substantially weakens its ability to promote physical activity. Worse yet, it may even have the unintended effect of decreasing physical activity by reducing inherent enjoyment of active hobbies (e.g., dancing, playing soccer) by suggesting that the reason for engaging in the activity is because it is necessary or "the right thing to do," rather than simply an enjoyable activity.
An additional issue with defining exercise as medicine is that adherence to medically prescribed regimes is often low (15-21), especially for difficult, complicated, or long term treatments. Poor adherence to medical regimes is even present when the consequences of non-adherence are severe, such as in the case of medication for coronary heart disease (21). Committing to an exercise routine requires significant effort and dedication, putting exercise adherence at great risk for low adherence. Although adherence is a difficult construct to assess, a review of the literature (22) found estimates of adherence between 4% and 93%, with most rates falling between 29% and 59%. A second review (23) found estimates of poor compliance in 30-50% of all patients, regardless of diagnosis or setting. These discouraging rates of adherence, especially considering the time consuming and long term nature of exercise that increase likelihood of low adherence, suggests that EiM's strategy of defining exercise as a medical treatment is misplaced. Lack of trust in physicians (24) or perceived discrimination (25) can cause patients to disregard their provider’s exercise “prescription,” further damaging the chance that patients will adhere to providers’ EiM recommendations.
Choice of Doctor-Patient Interactions as the Mode of Message Delivery
EiM aims to relay messages about the importance of exercise through doctor-patient interactions, but this limited strategy is a poor choice. First, many people do not have access to, or choose not to seek, healthcare services. People do not access health services for a wide range of reasons, including lack of insurance (26), lack of time (27), lack of nearby health facilities (28), and lack of trust in healthcare professionals or medicine (24). Rates of healthcare utilization are also low among minority groups (5, 29) and non-English speakers (30). Low income families may not have access to healthcare even if they have insurance due to barriers such as distance from healthcare providers and high financial costs beyond what is covered by insurance (31). The low rates of healthcare access and utilization among the uninsured and the consequent low rates of doctor-patient interaction in this population represents a significant weakness of EiM, particularly because members of low SES groups (1, 5, 32-33) and low education (1) have higher rates of inactivity and, therefore, are at greater need for exercise interventions than member of high SES groups. Among the general population, a 2007 study (34) reported that 21 percent of Americans has an annual preventive physical exam. This indicates that a large percentage of the population will not see a doctor unless they perceive a health problem requiring treatment, suggesting that many sedentary, but otherwise healthy people will not receive EiM's message. A recent review of health insurance and access (26) reported that 67% of adults, including both insured and uninsured individuals, had no contact with a health professional in the past year, similarly indicating EiM’s lack of reach.
Assuming patients have access to and seek healthcare services regularly, a provider’s advice may not result in increased exercise behavior. As previously mentioned, distrust (24) and perceived discrimination (25) in healthcare settings can cause patients to disregard doctors’ recommendations. Additionally, even if patients have a good trust relationship with their doctor and accept the message that exercise is medicine, intentions to exercise may improve without a corresponding increase in rates of exercise. The doctor-issued recommendation puts the responsibility to be physically active in the hands of the patient without addressing larger scale and upstream factors. Moreover, EiM’s success lies on the Health Belief Model-based premise that increasing salience of health risks associated with inactivity will increase intention to exercise. However, this logic is flawed and, even if intentions to exercise improve, behavior will not necessarily follow. The Health Belief Model assumes rational behavior, but it is clear that people often act irrationally. Moreover, the relationship between intention and behavior cannot be assumed. Research has shown that many who intend to engage in a behavior fail to do so (35) and that habits may inhibit the influence of intention on behavior (36). In order to improve behavior, EiM must do more than improve intentions to exercise through doctor-issued guidance.
Failure to Anticipate Barriers
A major flaw of EiM is its failure to anticipate barriers to exercise and its subsequent failure to address these barriers. The physical, “built” environment plays a substantial role in one’s choice to be physically active or inactive. Subjective assessment of physical activity in adolescents (37) and adults (38) as well as objective (39) measurement of physical activity in adults using accelerometers has shown that proximity to physical activity-related facilities (e.g., schools, parks, dance studios, YMCAs, swimming pools, bicycle rentals) increase engagement in physical activity. Similarly, the more convenient it is to exercise and the less convenient it is to be sedentary, the more likely an individual is to choose active over sedentary activities (40). Thus, the lack of areas and facilities suitable for exercise make it inconvenient and less likely that individuals will exercise, even if they know they should. Physical activity-related facilities tend to be less common in low SES and minority areas (37, 41). This barrier for low SES areas is particularly concerning because, as mentioned previously, rates of physical activity are lower in these population (1, 5, 32-33). An environment characterized by barriers to exercise will likely counteract the effect of increases in exercise intention motivated by EiM.
An additional, but related, barrier is the easy availability and convenience of alternative sedentary behaviors. According to behavioral economics, individuals weigh alternative choices based on costs and benefits as well as the proximity and tangibility of the costs and benefits (42). Behaviors with high immediate benefits and low immediate costs are preferred, even if high costs will be experienced later (43). The immediate costs of exercise (e.g., inconvenience, hard work, time, physical discomfort) are high and salient whereas the benefits promoted by EiM are distal and uncertain. Though exercise may reduce the risk of chronic disease, it is not a guarantee. Subsequently, from a behavioral economics perspective, a sedentary lifestyle may be perceived as more rewarding and higher value than an active lifestyle. While EiM aims to inform patients of exercise’s future health benefits, it focuses little attention on exercise’s more immediate benefits and does little to anticipate and downplay immediate costs of exercising. Evidence has shown that, given the choice between sedentary activity and exercise, most will choose sedentary activities (44). If access to sedentary behavior is restricted such that exercise is more convenient, however, exercise behavior increases (40, 45) demonstrating the utility of behavioral economics in exercise promotion programs. EiM’s failure to incorporate the ideas of behavioral economics inhibits its efficacy. Its chance of success would be far greater if it anticipated the barrier of readily available and tempting sedentary activities and encouraged perceptions of exercise as being more accessible and rewarding than sedentary behavior.
Conclusion
While the Exercise is Medicine program is intended to increase exercise behavior, its design has fundamental flaws that reduce its efficacy and may even be counterproductive. It oversimplifies the problem and the solution, creates potentially damaging associations between exercise and medical treatment, makes faulty assumptions, is too limited in scope, puts too much responsibility on the shoulders of individuals, and ignores substantial barriers. A novel intervention that capitalizes on social and behavior sciences theory and research would have higher chance of success in increasing exercise behavior and helping Americans reach national physical activity guidelines.

Active Communities Today: A Social Science-based Physical Activity Intervention – Maureen Harris
The Exercise is Medicine (EiM) initiative aims to battle the alarming prevalence of sedentary lifestyle and encourage adults to meet the national recommended guidelines for physical activity. Despite its good intentions, the program’s ignorance of social and behavioral principles greatly inhibits its efficacy. A previous critique of this program highlighted several crippling flaws. Here, an alternative program is proposed.
The Active Communities Today (ACT) initiative is based heavily on social science research. As its names suggests, it has three primary objectives. First, to get people active and moving, without necessarily framing exercise in a health context. Second, to engage communities, foster social support, avoid blaming individuals, promote policy changes to encourage activity, and to campaign for improvements in the built environment that facilitate physical activity. Third, to emphasize that the time for change is now; exercise behavior, not exercise intentions, will lead to public health improvements. These objectives are targeted by three key strategies that specifically address EiM’s fundamental weaknesses.
Strategy 1: Foster Intrinsic Motivation and Adherence
The EiM program defines exercise as “medicine” and employs medical terminology (e.g., “prescription”) throughout its materials. This definition is not only ineffective, but potentially counterproductive. By limiting the factors known to support intrinsic and internalized motivation, EiM reduces the likelihood that people will voluntarily choose to be active. The importance of protecting intrinsic motivation is more than theoretical. Applied research has shown that promotion of the factors that enhance internalization of motivation is positively related to exercise behavior (13, 46-49). ACT, guided by cognitive evaluation theory (CET; 10-11) and motivation research (e.g., 9-11, 14), promotes perceived choice, autonomy, self-efficacy, and the inherent enjoyment of physical activity to foster intrinsic/internalized motivation.
The program empowers people to make their own decisions and avoids directives and orders, with its primary goal being to allow exercise to become a naturally reinforcing activity. Through program materials and outreach events, ACT proposes a wide variety of activities, including competitive (e.g., road races and sports leagues), cooperative (e.g., recreational sports leagues and walking groups), and individual (e.g., health club workouts and swimming sessions) options from which people can choose, allowing people with all personality types to select an activity that is most appealing to them. The program recommends experimenting with nontraditional exercises (e.g., boxing or dance classes) to maximize interest and maintain satisfaction. Importantly, though abundant choices are offered, guidelines are provided. To make a noticeable public health impact, people must achieve a certain volume and intensity of physical activity. ACT advises participation in at least one activity for at least 30 minutes most days of the week in order to see short term benefits, such as increased energy and improved mood. As Whitehead notes (12), freedom of choice can be maintained within guidelines.
To enhance exercise self-efficacy, ACT encourages simple activities (e.g., brisk walking) as well as offering community classes and online tools to provide tips and skills on more complicated activities. At outreach events, fitness experts offer free consultations to help people design appropriate workout routines. While educational, the primary emphasis will be to encourage confidence. This aspect of the program is critical as self-efficacy has been shown to predict exercise behavior (46, 48-49) and adherence (13, 47).
ACT markets exercise as fun, with the goal of helping adults reconnect with the enjoyment of playful activity of childhood and to incorporate daily activity into their lifestyle. Defining exercise as a positive and pleasurable activity portrays physical activity as a satisfying choice. Furthermore, the expectation that exercise will be enjoyable increases the likelihood that an individual will perceive exercise as enjoyable. Cognitive biases often cause us to see what we want to see or experience what we predict we will experience (50). Positive exercise expectancies have been associated with exercise behavior (51).
By facilitating the factors necessary for intrinsic/internalized motivation, ACT simultaneously addresses EiM’s likely problem with poor adherence. A smoking cessation intervention that supported autonomy and perceived competence increased long term adherence to tobacco abstinence (52). Similarly, it has been demonstrated that those who adopt exercise as a personal value are more likely to adhere to regular physical activity (9).
Strategy 2: Employ Widespread, Effective Communication
As noted, many people do not see their doctor for various reasons. Even among those that do see a healthcare provider, many lack trust in him or her, meaning that directives from a provider may be disregarded. In order to communicate the core program messages effectively, ACT employs a multifaceted communication strategy.
To maximize distribution, print, radio, and television ads are used to broadcast ACT’s key messages widely. Posters are placed in public buses and trains as well as high traffic centers such as libraries, schools, and outside of grocery stores and banks. Radio and television ads are aired several times a week. Local outreach events featuring ACT representatives bring key concepts directly to community members. A website offers confidential guidance, encouragement, and tools to get started. Visitors to the site will be encouraged to offer suggestions for site improvements to maximize its utility (53). A network of message boards hosted on the site will offer a forum for social support and exchange of questions and answers. Importantly, medical experts will moderate the boards to ensure the accuracy of answers provided by community members. The site will also feature a space for individuals to get involved in policy change by reporting concerns (e.g., crime levels render neighborhood unsafe for outdoor exercise) and requesting changes (e.g., construction of bike lanes on city streets). This space is intended to open a dialogue between community members and policy makers.
In addition to being well-distributed, it is equally important that ACT’s communications are interpreted positively. This involves appealing to values of the intended audience (54), as assessed by pilot focus groups and survey samples, rather than the values of ACT staff. As an example, the program promotes commuting by bike rather than car to be “green” and doing house/yard work on your own rather than hiring landscapers to be thrifty. ACT’s materials and events feature a wide range of regular people with whom the target population can relate, including members of various racial and cultural groups, young and old, male and female. Beyond facilitating social learning (55), this shows that exercise is truly for everyone and helps develop imagery of people having fun being active. The aim is for members of the target population to begin to imagine themselves in an active lifestyle and consider adoption of an active lifestyle as an achievable goal.
Strategy 3: Reduce Barriers and Market Immediate Benefits
ACT is firmly based on behavioral economic principles and recognizes that there are infinite sedentary activities competing with exercise to fill the limited number of hours in a day. To portray exercise as a valuable choice, the short term benefits must be emphasized while short term costs are minimized (42). The program’s goal is to sell the idea that exercise is a small investment with a large immediate reward.
ACT works to reduce immediate costs by making physical activity accessible and convenient. A major obstacle in the widespread adoption of active lifestyles is the lack of exercise-friendly environments. With unsafe streets, car-dependent communities, and neighborhoods lacking recreational centers, finding opportunities to be active can be difficult, even if an individual has an intention to be active. In order to make improvements in physical environments, ACT works closely with government officials, community developers, and business leaders. The program sponsors grassroots organizations to campaign for change at the town and city level while opening a parallel dialogue with state and federal leaders. As mentioned in the second section, ACT involves the community members in this dialogue. Short term projects include establishment of bike share programs in urban centers. The long term vision is for development of high-density, “walkable” communities with low crime rates, low pollution, and abundant physical activity-associated facilities (e.g., recreational centers, swimming pools, tennis courts). These attributes are associated with higher rates of physical activity (e.g., 56-58), and a recent case study reported that increased access to recreational resources raised physical activity levels (59).
In addition to reducing structural barriers, ACT reduces perceived immediate costs by showing that exercise can be just as easy and uncomplicated as sedentary behaviors. The program website and print materials offer suggestions on how to incorporate simple exercise and non-exercise physical activity (e.g., walking for transportation, vigorous housework) into a daily routine. Moreover, it suggests inexpensive activities that can be done without leaving the house (e.g., exercise videos, jumping rope, dancing), and reminds people that if they cannot tolerate high intensity exercise, they can still reap benefits from higher frequency, lower intensity workouts.
Keeping in line with behavioral economic principles, the immediate benefits of physical activity are advertised much more heavily than long term health benefits. Program materials highlight increased energy and vitality, improved mood, higher quality sleep, improved mental functioning, reduction in mild depression, increased self-esteem, and even higher sex satisfaction. Fun activities that are considered pleasurable rather than painful (playing tag with the kids, playing tennis with a friend or spouse) are highlighted. To help physical activity gain an extra edge over sedentary activities, behaviors such as television viewing and video game playing are marketed as having few benefits. Time spent TV viewing has been shown to be inversely related to leisure time physical activity in women (60), girls (61), and adolescent boys and girls (62), suggesting that reducing TV viewing may encourage activity.
Conclusion
ACT is a broad, multifaceted program. It works primarily above the individual level to create large scale changes in the culture, physical environment, and social environment. In parallel, it targets individual level behavior by reframing exercise with positive terms and promoting exercise’s inherently reinforcing properties.



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D.A.R.E. to Know the Truth: The Ineffectiveness of DARE Due to an Inability in Addressing Context and Reality – Danielle Tuft

Adolescent drug use has been a continuous problem that the U.S has had to face and one which has yet to be controlled. In response to this, preventions focused on youth have become a larger focus with hopes that kids will learn to avoid negative peer pressure and recognize the damaging consequences of drug use. School-based drug use prevention programs have been a fundamental part of the US anti drug campaign since the 1970s (1). These programs allow for early prevention opportunities as well as include an already existing structured environment useful for the introduction of important and potentially unknown information.
Of the anti drug campaigns that have been used in the U.S., project DARE (Drug Abuse Resistance Education) has become the most widely disseminated school-based prevention program (2). DARE was created in 1983 as a product of a collaboration between the Los Angeles Police Department and the Los Angeles School District to teach drug use prevention curriculum primarily in elementary schools, though it grew to include middle schools and high schools. Its curriculum, taught by police officers, focuses on providing information about drugs, decision making skills, building self-esteem, and finding alternatives to drugs (1). According to the DARE website, the program benefits children in more than 300,000 classrooms and in all 50 states, as well as millions of children in other countries (3).
Over the past 25 years, many studies have found that the DARE program to be ineffective (1,4). A 5 year longitudinal evaluation of the effectiveness of DARE concluded in 1996 that “no statistically significant impacts of the intervention were observed with respect to the cigarette, alcohol, or marijuana use” (2). Beyond individual reports of the ineffectiveness of the DARE program, the federal government has also recognized this conclusion. The Department of Education prohibits schools from using federally allocated funds on the program as they have determined it ineffective and in 2001, the U.S. Surgeon General put DARE into the group of “ineffective programs”. It is estimated that DARE costs $1-1.3 billion dollars each year, yet it is still widely used regardless of the fact that many studies and organizations have found the program to be ineffective (5).
Failure to Recognize the Importance of Cultural Context
The curriculum of DARE is set up in such a way that it addresses large numbers of school children at one time. While there are some opportunities to focus on the individual, most of the curriculum is addressed to an entire class, or in some situations, an entire school. The program lacks the structure to allow for the exploration of individual students’ different social, economic, or cultural backgrounds and their behavior in response to those contexts.
It has been shown that students respond more favorably to drug prevention programs when the programs visibly incorporate their culture and allow students to be represented (6). It makes sense that a program which directly addresses cultural situations for a specific person or group of people would resonate more with that person. Many anti drug programs have failed to consider the importance of ethnicity and culture and instead have opted for a standardized curriculum assuming it to be effective for all (6). This is the case with DARE as it does not incorporate cultural situations into their curriculum but instead uses role playing focused on simple peer pressure situations, such as “What would you do if your friend offered you drugs?”. There is no exploration into the possibility that the reaction to this question may differ depending in what cultural situation it is asked. Even more, DARE is used throughout the country in cities with many different resources and demographics, yet the same classes and topics are taught with the same methods. It has been argued that standardized prevention messages can and do enforce “dominant cultural values that do not validate or utilize minority children’s cultural experiences” (6).
DARE does not account for the diversity found in many schools and the structured curriculum limits the program’s ability to use different communication techniques or introduce other possible cultural values when dealing with different students from different backgrounds. Minority youth may be underrepresented if prevention materials are constructed from middle class, white culture (6). One book, in discussing a student approved approach regarding the relationship between the officers and students, quoted a student who said that “They need to get to know the kids personally and find out why they’re using drugs or whatever. You need to know the kids and find out why they’re doing something before you can do anything about it” (7). It cannot be assumed that every person sees drug use in the same way, especially considering that many religions use alcohol in a positive manner during rituals or that a child with parents that smoke may perceive cigarettes different from a child who has grown up in a smoke free home. It may be much more difficult for a student to “just say no” when they live in a community where drug related issues are constant or where trafficking drugs is a prevalent option for youth. With this in mind, it is easy to argue that since DARE does not allow for cultural and ethnic differences, many children may feel that the program does not apply to them.
Incorrect Choice in Leaders
The Communications Theory is a widely used theory within public health and one which touches upon the importance of “who says what to whom in what channel with what effect” (8). This theory clearly points to the importance of recognizing the person who is conveying the message and what effects may be brought about by that choice.
Since its inception, DARE has relied upon police officers to be the “teachers” of anti drug information. DARE explains that there are multiple benefits to the use of police officers, such as the fact that it “humanizes” the officers and allows youth to relate to them as people or that it removes police from the enforcement role and allows students to see them in a different one (3). While to some effect, there may be a “hero” factor attributed to police by young people, the police officer’s authoritative position is still kept. They come dressed in uniform and as a special guest, separating themselves from the youth. Even more, in many situations the officers may lecture, thus once again putting themselves above the youth and in an authoritative position as the person who has the answers.
It is also very possible that the perceptions students have of officers may differ greatly. It is unlikely that a student who comes from a neighborhood with high crime rates and constant police action will be able to recognize a police officer as credible or to see them in a positive manner. DARE is a program that lasts about one hour a week for between 10 to 17 weeks. The officers with whom students are to bond with are not considered to be normal members of the educational community and it could be argued that their infrequent interaction with the youth make it difficult for the youth to cement positive relationships with them.
It has been found that peer led programs have been better at reducing substance abuse than programs without a peer component, yet DARE has continuously used police officers as the main person to disperse anti drug information (9). Children cannot relate to them and are even more likely to disregard the advice they may receive from them. Early adolescence is a period in which children shift from being primarily influenced by their parents to being primarily influenced by their peers (6). With this in mind, it does not make sense that DARE would choose adults, especially ones with no previous relationship with the youth, to attempt to influence the ideas and behaviors of early adolescents.
Unrealistic Goals and Failure to Look Past the Individual
The DARE program uses an abstinence approach, telling students that they should never do drugs at all rather than recognizing that many students at some point experiment. It has been hypothesized that this approach may actually be damaging to prevention efforts as it may provoke rebellious behavior from students already experimenting (10). It is unlikely that a student will never experiment, and in the case of alcohol, DARE does not provide methods in which to avoid actual alcohol abuse once a student reaches the legal age to drink. In the case of adolescents who have experience with substances, advocating no use may actually lead to an increase in drug use, as they may reject the intervention (10). DARE does not address students who are already experimenting and the curriculum gives them no reason to stop because the program no longer relates to them as they have not abstained from drug use. A person like this may feel that they have no place within the current program. Even youth who have not experimented may recognize the program to be unrealistic and view it as ineffective or not applicable to current youth.
It is clear to see the unrealistic expectations of the DARE program simply within its well known slogan of “Just Say No”. The simplistic nature of the statement seems to allude to a mistaken idea that turning down drugs is as easy as saying a couple words. DARE, like many other public health programs, focuses solely on the individual level, and fails to look at reasons beyond individual control for unhealthy behaviors. This approach focuses on providing individuals the tools they need, such as education and skills, to say no; however this clearly is not enough as approximately 6,000 youth try a cigarette per day (11). Similar to looking at cultural backgrounds as reasons for behavioral choices, it is necessary to look at the larger reasons beyond a person themselves as to why a student may say “yes” instead.
Conclusion
The U.S. has recognized for years that adolescent drug use is a huge problem and has encouraged the use of school based prevention programs to combat it. Although many of these programs have been created, none have been as prevalent as the DARE program. However, DARE’s ineffectiveness in reducing adolescent drug use behavior clearly contrasts its popularity and prevalence (1). Aspects of the program’s ineffectiveness could be attributed to its inability to account for certain ideas found within social theories.
In order for DARE to become more effective it must recognize the problems it currently has and reformat its curriculum. The program must look past the individual level and attempt to find reasons for unhealthy behavior within the cultural context of its students as well as welcome the different views and perceptions student have on drugs. DARE must also realize that while there may be some uses for police officers in the program, they cannot be the main distributor of information as many students may not see them in a positive light. Lastly, it is important that DARE adjust its goals and realize that it is unlikely to end all adolescent drug use but to instead focus on how to control it or how to offer other options to students who already are or have the potential of experimenting with drugs.
Introduction
Recognizing problems in the structure and implementation of the DARE program allows for an opportunity to address possible changes and a new intervention that uses different health behavior theories and correct those issues found in DARE. While a completely new intervention is not absolutely necessary, a revamp of the traditional DARE program is needed. Studies have continued to show DARE to be ineffective in the long term and a new anti-drug intervention which takes cultural theory, social network theory, and harm reduction into account must be put into action (1,4).
Intervention
The intervention would address the three main faults discussed in regards to the current DARE program, those being its failure to recognize cultural context, employing ineffective leaders, and putting forth unrealistic goals. The revamped program would be much more comprehensive and look at possible social and cultural contexts in regards to drug use. It would also be designed in a way so that it could be reworked to fit a particular geographic setting or demographic.
First, the program would make use of the Cultural Theory and recognize the need for different techniques for different groups of people based on their cultural background and understandings of health and addiction. The program would include discussions that are targeted and tailored to specific groups, particularly different ethnic groups, in an attempt to be more effective after recognizing the differences in drug use rates among different ethnicities and cultures. The intervention would also be created with the use of focus groups, employing a specific cultures view on alcohol use, smoking, and illicit drug use so as to use a group of people’s own views on drug use to influence their health behaviors.
Second, it would be a long-term program starting in elementary school and continuing through middle and high school, with discussions and seminars happening at least 50% of the weeks in an academic school year. The intervention would take into account the Social Network Theory and the importance of peers and their influence. The discussions would be led by older peer leaders who share commonalities beyond simply age with the targeted age group, such as middle school students leading discussions for elementary students and high school students leading for middle school students. This intervention would still use police officers but rather than lead discussions in an authoritative manner, they would join discussion groups as participants in order to allow for a more even relationship between themselves and the students. This would allow police officers to still form positive relationships with students without “scaring” students or exacerbating the negative impression some students may have of the police force. The program would also employ a buddy system between younger peers and responsible older peers with similar cultural and social backgrounds, in order to provide a positive role model and to show actual alternatives to drug use.
Lastly, the program would be designed in such a way to meet the changing attitudes and social contexts that come with growing up. This revamped intervention would take into account the changing attitudes of alcohol and marijuana within the American public, such as the increasing push to legalize marijuana. The program would integrate use reduction goals with harm reduction goals, in an attempt to include all students as well as to teach students how to be safe or how to handle situations such as a friend who is drunk and needs help. Harm reduction goals would also give a student the skills needed to be safe once they reach the legal age to drink alcohol or smoke cigarettes. The integration would move from a heavier focus on use reduction to a heavier focus on harm reduction as the students get older. For example, the elementary based program would be more focused on use reduction, though may find in certain communities that harm reduction is necessary while, the high school program would still promote abstinence while recognizing the growing need to rely more heavily on harm reduction.
Using the Cultural Theory and Recognizing the Cultural Context
When youth are able to see themselves in presented situations, they are more likely to relate to and support the prevention messages (6). The Cultural Theory recognizes that a behavior related to health is influenced by a person’s understanding about its meaning or is a result from a lifestyle built around meanings, symbols and values, as they are connected to a larger social structure (8). Through this theory, which asks questions such as “what does it mean to be healthy?” this new intervention is able to account for different students varying understandings of drug use (8). Its use in creating the discussions and program topics, allow the intervention to change methods depending on how one group may view alcohol in a larger context or the fact that students who live in neighborhoods with heavy drug use may see dealing or using as inevitable. The targeted nature of this intervention also allows for the opportunity to do this rather than approach a larger group with multiple backgrounds using only one view of drug use.
The use of the Cultural Theory would also allow for cultural tailoring, defined as the “process of creating culturally sensitive interventions” (12). As part of this intervention there would be a focus on both the surface structure and deep structure, two dimensions of cultural sensitivity. It is explained that surface structure looks to match intervention materials and methods to the observable characteristics of a population, such as music, food, preferred clothing, and language. Deep structure on the other hand involves incorporating outside forces, such as culture, history, and environment in an effort to influence behaviors (12). The employment of these methods would most likely be more effective in reducing drug use both because students would understand drug use in a context familiar to them and the influences that are more problematic to a specific group can be addressed rather than spending time on issues that one cultural group hold to be insignificant.
In order for the intervention to be effective, focus groups must be a major part of the development. Focus groups have been found to be effective in creating culturally sensitive intervention message (6,12). Youth from the targeted groups must be involved in order to understand the realities of the social and cultural context as well as in an attempt to avoid stereotyping.
The Social Network Theory and Choosing Effective Leaders
This revamped intervention pairs up younger students to older students who serve as positive role models and creates a support system that is outside the student’s normal environment or friend base. The intervention does so in accordance with Social Network Theory which recognizes that “relationships between and among individuals are important, as is how the nature of those relationships influences beliefs and behavior” and that these relationships play an important role as to whether a person partakes in risky health behavior or not (8). More specifically related to drug use, the Social Network Theory means that students are heavily influenced by the drug use habits of their family, community, or friends. With this in mind, it is important that young students are able to see positive role models and identify how responsible youth avoid drug use.
Unlike the traditional DARE program, this intervention uses peers to lead discussions and interactive activities and places police officers in a more even level with students. As addressed in the previous critique, it has been found that peer-led programs are more effective at drug use reduction than prevention programs that lack a peer component (9). Using youth that students can relate to is important in attempting to change behavioral norms. Peers are more effective as leaders in that they seem more credible to students, which encourages those students to actually support the anti-drug information discussed, and that norms created through use of a discussion group are more likely to continue outside of school (9). As part of this intervention, using middle school students to help lead discussions for elementary students, provides role models who do not partake in drugs and may impart to the youth that drinking and drug use is not a norm and that it is not necessary to be “cool”. Particularly, using youth who have avoided drug use in an area where it may be prevalent may show students that it is not inevitable and that there are people who they can go to that will help them keep healthy behaviors.
Integrating Harm Reduction Approach with Use Reduction Approach
There has been a growing movement in creating a framework for a harm reduction approach in public health intervention, which is rooted in the awareness of adolescent psychosocial development where curiosity and a willingness to experiment are prevalent (13). Today, youth are seeing states continued interest in legalizing marijuana for both medical and leisure or their parents drinking a glass of wine at dinner. Even more, students eventually reach an age where it is legal to consume alcohol or smoke cigarettes, yet the traditional DARE program disregards this and does not provide students with the skills needed to partake in alcohol use safely. It has been argued that “school based prevention programs cannot be effective because they are inconsistent with the messages that adolescents receive from the larger social environment” (13)
With this in mind, this new intervention includes a harm reduction approach, primarily aimed at older youth. The approach focuses on the principles of harm reduction and uses them pragmatically, offering information about drugs rather than solely against them (13). It is unrealistic to assume that youth will abstain completely from drugs and it is important to offer safe options and teach moderation skills. In addition to promoting safer use, this approach allows the program to reach out to students who may have already experimented or are currently use drugs.
Conclusion
This revamped intervention corrects the faults found in the traditional DARE program though the use of the Social Network Theory and the Cultural Theory. It provides a program that is better at dealing with growing multiculturalism and is accessible to many more students than the original program. It also moves away from the abstinence only approach and accepts the need to educate students on safe use. Overall, an intervention like this may be much more effective and positive to students.
References
1. Ennett, S, et al. How Effective is Drug Abuse Resistance Education? A Meta-Analysis of Project DARE Outcome Evaluations. American Journal of Public Health 1994; 84: 1394-1401.
2. Clayton RR, et al. The Effectiveness of Drug Abuse Resistance Education (Project DARE): 5-Year Follow-Up Results. Preventive Medicine 1996; 25: 307-318.
3. D.A.R.E. Drug Abuse Resistance Education. About D.A.R.E. Los Angeles: Drug Abuse Resistance Education. http://www.dare.com.
4. West S, O’Neal K. Project D.A.R.E Outcome Effectiveness Revisted. Research and Practice 2004; 94: 1027-1029.
5. Kalishman A. Drug Policy Alliance Network. D.A.R.E. Fact Sheet. New York: Drug Policy Network. http://www.drugpolicy.org.
6. Gosin M, Marsiglia F, Hecht M. keeping’ it R.E.A.L.: A Drug Resistance Curriculum Tailored to The Strengths and Needs of Pre-adolescents of the Southwest. J. Drug Education 2003; 33: 119-142.
7. Orcutt J, Rudy D. Drugs, Alcohol, and Social Problems. U.S: Rowman and Littlefield Publishers, 2003.
8. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
9. Valente TW, et. al. Peer Acceleration: Effects of a Social Network Tailored Substance Abuse Prevention Program Among High-risk Adolescents. Addiction 2007; 102: 1804-1815
10. Mash E, Barkley R. Treatment of Childhood Disorders. NY: Guilford Press, 2006.
11. Bergsma L. Center for Media Literacy. Media Literacy and Prevention: Going Beyond “Just Say No”. CA: Center for Media Literacy. http://www.medialit.com
12. Resnicow, Ken, et al. Cultural Sensitivity in Substance Use Prevention. Journal of Community Psychology 2000;28: 271-290.
13. Erickson, Patricia G. Reducing the Harm of Adolescent Substance Use. Canadian Medical Association 1997; 156: 1397-1399.

“Think. Don’t Smoke”: Why the Health Belief Model Makes the Campaign Ineffective- Simona Shuster

"In order to motivate someone to quit, you have to provoke a strong emotional response," Jenna Mandel-Ricci, director of special projects for the Department of Health, told the Daily News. "If we run ads that people don't remember or that don't affect people, then people won't call for help (1).” This statement can be extrapolated to describe any situation, particularly anti-smoking. Many a campaign has been created to show the ravages of smoking on the psyche and body on youth and adults alike, but to no avail. About half of all smokers who keep smoking will end up dying from a smoking-related illness (2). If information and campaigns are so prevalent about the horrifying effects of smoking, why is youth still determined to smoke?
Most anti-smoking campaigns remain failures because their messages are unclear or weak. Millions of dollars have been wasted in efforts trying to make people quit, but much of the ads are only informational in nature. Ironically, it is more the colorful and fun pro-smoking campaigns and billboards that most people remember and not their antithesis. Philip Morris is notorious for making the Marlboro Man, the iconic rugged man on his horse, smoking his cigarette, because that is what real men do, and to which other men can only aspire. Thus, when Philip Morris set out the venture to dissuade youth from smoking, most were surprised, but admittedly pleased initially with the “Think. Don’t Smoke” campaign that resulted. However, what looks too good to be true often is and this campaign, with its official message of discouraging youth from smoking, brings out many subliminal messages, least of which is the adage that was intended.
As an anti-smoking campaign, “Think, Don’t Smoke” failed miserably because it based its advertisements on the Health Belief Model. Many facets of the Health Belief Model do not hold true when applied to this public health epidemic. Thus, the campaigns built upon them can only have limited success in their endeavor to keep adolescents off cigarettes. This essay will focus on the 3 most influential flaws of the “Think. Don’t Smoke” campaign committed by Philip Morris, based on the Health Belief Model.
The Health Belief Model is the oldest model and upon which much of public health campaigns still rely. Its main premise is that human beings are rational creatures and behave in predictable patterns. Therefore, once the intent is present, it will lead to behavior. However, several crucial components stem into the intention. Perceived susceptibility is the degree to which a person feels at risk for a health problem. If the susceptibility is high, the person will have increased chances of committing the behavior. Perceived severity focuses on the premise that the person may believe the consequences of the problem to be harsh. Perceived benefits are the positive outcomes a person believes will result from the action, whereas the perceived barriers are the exact opposite as the negative outcomes. Once a person has carefully accessed all of the pros and cons of the making that choice, and it is their intention to do it, they will go ahead and commence with that conclusion.
Flaw #1: Youth Act in a Predictable Manner
The first incorrect assumption is the most hindering to public health campaigns and entails the premise mentioned earlier that youth will act in a predictable manner. However, people are predictably irrational and youth make it their stance to be deliberately so. The research that Philip Morris used primarily failed to account for the rationale of youth and their rebellious nature and determination to seek full independence and maintain decision making authority. It is precisely their irrationality that makes the ads unrealistic and to which adolescents cannot relate. The children found the Philip Morris adverts to be the least effective of all in making them “stop and think” about not smoking. Some of the respondents said that the Philip Morris adverts sounded more like a parental lecture, and overall there was a feeling that they lacked substance and good reasons not to smoke (3). Studies have proven that the worst campaigns are those reflecting an authority figure telling the adolescents what to do. In one example, a young teen is going out with friends and upon leaving, her father reminds her not to drink or smoke. She replies that she knows and does not do so when someone tries to offer her a cigarette in her group. The ad is cleverly done because the girl is in a group of her peers and says no. However, if one pays attention to the subtleties of the advert, he will notice that she did not even glance at the person offering her a cigarette which means that she either does not know this person or does not hold him in high regard. If she did, she would have more likely accepted his offer of a cigarette.
The ads are also clever in that they only focus on teens as their current ages and do not extrapolate into the future. It is a well documented fact that young adults do not think about their health in the future. The focus is more short-term and during their teen years, adolescents have yet to acquire any diseases that could be attributed to smoking. Heart disease and lung cancer seems a long way away to a 16 year old girl starting to smoke because of peer pressure. Her attitude may be “anyway by the time I get to 40, they will have a cure(4).” There are also no perceived barriers to smoking during adolescence because the negative outcomes will be much later in life. The perceived severity is greatly reduced as teenagers feel, precisely as a result of their youth, that they will be able to quit whenever they want. That is very true in that they will quit and start up again. Nicotine, a drug found naturally in tobacco, is highly addictive -- as addictive as heroin or cocaine. Over time, a person becomes physically and emotionally addicted to (dependent on) nicotine. Studies have shown that smokers must deal with both the physical and psychological (mental) dependence to quit and stay quit (2).
Flaw #2: The Health Belief Model doesn’t Account for External Factors and Social Norms

The next flaw of the “Think. Don’t Smoke” campaign is that, because it is based on the Health Belief Model, it does not take into account external factors and social norms. A University of Georgia study found that youth will only respond to a campaign because of peer pressure; they assume that their friends are interested and will be listening. Otherwise, the ads appear to stimulate the rebellious and curious nature of youth, making them more interested in smoking (5). One advert that Philip Morris uses does have a group of teenagers sitting around the steps leading to a beach and discussing how different all of them are and that is what makes them unique (6). This is the reason they cite for not smoking. Some teenagers may react well to this ad, but if they think their friends will scoff at it or notice their peers making fun of it, then they will partake in this action. "Perception is sometimes more powerful than actual behavior, that it doesn't necessarily matter how your friends respond to the ads, but how you think your friends are responding (5).” While Phillip Morris tries to capture individuality or independence that adolescents crave during their teen years by showing all of the teenagers together, it still fails to make a big impact upon other teens in terms of anti-smoking, but does a great job of convincing them to pursue the bad behavior. Those who do not share the thoughts and feelings of the youths presented in the “Think. Don’t Smoke” campaign simply do not relate to the ad. This latter group, however, has greater potential to become future smokers and should therefore be the main focus of a tobacco counter-marketing campaign (7). The point is supposed to be to make the advertisements very pragmatic so that teens can realistically see themselves in those positions and being able to avoid succumbing to peer pressure.
Flaw #3: The Slogan Is a Failure
The final flaw in the “Think. Don’t Smoke” campaign is the actual failure of the slogan itself. Firstly, the slogan manifests itself in a derogatory and patronizing manner, which teenagers will immediately find offensive. When one is commanded to perform an action, it will immediately set off a rebellious attitude against the stated action, despite the perceived benefits of knowing that the consequences of performing that action would be positive. Furthermore, the authoritative and negative tone of the slogan draws teenagers to counteract out of spite. Philip Morris says it has spent more than $1 billion on its youth smoking prevention programs since 1998 and that it devised its current advertising campaign on the advice of experts who deem parental influence extremely important (8). Clearly their research is not very thorough because adolescents do not want to be told what to do, especially not by adults. Therefore, the slogan is stating if one thinks, then he is listening to what adults have to say, and he won’t smoke. Teenagers do not want to be associated with thinkers because they are the “not cool” crowd. The ad is counter-productive in the sense that it specifically draws out the disobedient nature of youth who will relish the thought of smoking just to avoid being mislabeled into the wrong crowd. This is again where societal norms take precedence over what the individual may think. Teenagers do not want to be different, and instead form cliques that then generate the label to all who “fit in.” The campaign has failed to take into account what adolescents hold in esteem and have created ads that are ridiculous in content and scope. Also, a very basic and obvious critique of the campaign is the tackiness of the ads. It gives one the impression that the Anti-Smoking campaign, albeit spending over $100 million dollars to create, couldn’t really care less about the anti-smoking message and that each campaign involved the most minimal of efforts on the part of the creators and writers. Youth seeing these adverts could disregard them based on these tenets alone, not even bothering to query about the message the campaign is trying to convey. The campaign did the least well among youths in greatest need of messages that discourage smoking (9).
The failure of the “Think. Don’t Smoke” campaign can be relegated to the fact that Philip Morris created these adverts. It would be prudent to remember that these people are in the market of promoting cigarette smoking and addiction because it keeps them in business. They would never create logical campaigns to promote anti-smoking because they would lose their revenue base. For each smoker who dies, the firm then taps into the youth markets and recruits more by using more of these campaigns. Oddly enough, the Philip Morris website itself indicates that they are actively promoting youth anti-smoking and that their product is intended for adults. These phrases will make the idea of the all mighty cigarette even more idealistic to young adults who see this as a toy that can only be played with once they are grown. They will do everything in their power to obtain this product to be able to brag that they are performing the action only meant for adults. This is a predictable behavior of human nature. One will always want what one “can’t have.” A new study by the American Legacy Foundation gives conclusive evidence that Philip Morris’ latest efforts to clean up its image by running advertisements purporting to discourage youth smoking are nothing more than a sham. Instead of reducing youth smoking, they insidiously encourage kids to use tobacco and become addicted Philip Morris customers (10).

Using Advertising and Marketing Theories in “Infect Truth” to Counteract the Health Belief Model and “Think. Don’t Smoke.”- Simona Shuster

Insofar as many anti-smoking campaigns have failed to live up to the promise of their campaigns, “Infect Truth” comes out with a stunning victory over other efforts as they base their campaigns on young adults’ and adolescents’ core values. The “Infect Truth” adverts are the exemplary counterpart to the “Think. Don’t Smoke” campaign launched by Philip Morris. The campaign features young adults revealing messages about tobacco companies- they are often campy and catchy, with sing-song phrases and musicals. It is the only national smoking prevention campaign not directed by the tobacco industry, which exposes the tactics of the tobacco industry, the truth about addiction, and the health effects and social consequences of smoking. It is a national peer-to-peer intervention that works (11). The messages are very cleverly designed because they criticize the tobacco slogans in a manner that is clearly understandable to the layman.
“Infect Truth” resulted from a victory of the state of Florida over the tobacco companies in 1998. The State took the $13 billion per year settlement and formed the Florida Tobacco Pilot Program in 1997. The program set out to drive a wedge between the tobacco industry's advertising and a youth audience. It not only assembled a team of advertising and public relations firms to develop the marketing portion of the campaign but also directly polled Florida's youth. From this, emerged “Infect the Truth” in 2000, the campaign concept of a youth movement against tobacco companies promoted through a youth-driven advertising campaign (12).
The campaign uses the social models of Advertising and Marketing Theories, based not on the individual but rather on society as a whole, to drive its point. Advertising and Marketing Theories are ubiquitous in the advertisements and show “Infect Truth” as a global brand that all young adults now recognize. Advertising theory posits that the way to have people behave is to make them a promise and provide support for that promise that will in turn help people behave in said manner. In this instance, the entire premise and promise of the “Infect Truth” campaign is if youth knows the truth about smoking and its effects and more importantly, can relate to the messages conveyed, they will be less likely to begin smoking or continue smoking if already started. Marketing Theory takes Advertising Theory one more level with the branding of the product- which in this case, is “infecting truth” about smoking. The campaign does an excellent job of correcting the three flaws that were prevalent in the “Think. Don’t Smoke” campaign.
Flaw #1: Youth Act in a Predictable Manner
The “Think. Don’t Smoke” advertisements focused on campaigns that had children listening to authority figures. “Infect Truth” advertisements feature edgy, and rebellious multi ethnic teens rejecting tobacco marketing efforts and revealing stark facts about the deadly nature of tobacco (13) “Truth” accounts for the rebelliousness of teenagers by showing them ridiculous adverts based on the real results of cigarette smoking. The adverts work because of their ludicrous nature- the whole scheme is that as the commercial is over, one shakes his head and says “wow, that was stupid” and that is exactly the point because it makes the person stop and focus exactly on the meaning and in turn grabs his attention to the inanity of smoking. The advert entitled the Sunny Side of Truth (14) shows two young males in front of a large corporate edifice, meant to portray the tobacco company, with a table filled with poisons outlining the chemicals found in cigarettes. One says to the other- “cigarette companies must really hate us.” To which the other replies, “or love us- it’s called tough love,” then they break into song and dance about how cigarette smoking maims and kills. The adage that comes to mind with this commercial is “tough love- whatever doesn’t kill you, will only make you stronger.” Ironically, cigarettes will kill, or make one significantly weaker. The adverts use both a white and black actor so as to not prejudice the commercial. Framing the adverts in such a manner encompasses and promotes the unity of all teenagers, indicating that youth smoking is a problem across ethnicities. There are no parental roles showcased in these adverts- solely teenagers making a mockery of the tobacco industry so that other teenagers can see this and relate.
Seventy-five percent of all teenagers between the ages of 12 and 17 state that they can accurately describe one or more of the Truth campaigns and that the adverts gave them good reasons not to smoke (15). The point is to have young children not smoke now so that they need not worry about their future health, as it relates to smoking. “The Truth” campaign provides a return on investment that would make the greediest corporate CEOs salivate and if the Truth campaign continues for another five years (2009-2014) with similar effectiveness, there will be up to 500,000 fewer youth smokers with savings of up to $9 billion in future medical costs (11).
Flaw #2: The Health Belief Model doesn’t Account for External Factors and Social Norms

The “Infect Truth” campaigns, as based on the Advertising and Marketing Theories, greatly focus on external factors and social norms. These adverts intentionally do not use the Health Belief Model because of its individual nature. The adverts’ foundation, the promise indicated in the commercials, is their ludicrous nature that amalgamates youths’ opinion. The commercials unify youth by exploiting the asininity of the messages. The very nature of the message is intended to have youth scoff at it, but simultaneously pay attention. Therefore, no alienation will occur amongst teenagers as they will think the same. The advert entitled Box of Poison (16) shows several teenagers walking into a shipment facility and asking if they can ship cyanide and poison. The workers are astounded and obviously say that these ingredients are hazardous material and therefore illegal to ship. The teenagers entirely agree, but also maintain their stance that they want to send the product, finally letting on that the product is a box of cigarettes. The commercial manifests itself in a sneaky, but witty manner, in that the contents are presented first, before the merchandise is revealed. Furthermore, the commercial imparts information without being obnoxious and alienating people. Teenagers find the commercial to be very relevant and significantly changed their attitudes towards tobacco. “The Truth” campaign is successful precisely because it takes into account [advertising theory] and develops its ads using the best scientific research about how young people make their decisions about whether to smoke and what is most likely to influence them not to smoke [which is social perceptions] (13).
Flaw #3: The Slogan is a Failure
“Infect Truth,” unlike “Think. Don’t Smoke.” is a very straightforward slogan. There is no mockery, no gimmicks being implied nor orders being inferred. It is the truth that the adverts are maintaining and therefore cannot be labeled anything else. There are no subliminal messages and the meaning, most importantly, is very clear. The slogans in every truth advert also feature “Knowledge is contagious.” This is a very pithy comment, and yet absolutely genius, because it resonates with people. It is human nature to share details of what one has learned or heard, regardless of whether groups are discussing gossip, local and national news or more trivial matters. People communicate constantly and will discuss these adverts. Therefore, knowledge really is contagious. Case in point is the advert featuring the crawling babies with orange shirts (17). It immediately grabs one’s attention because they are “crying babies,” but also because of the message written on the shirt, stating that babies avoid second hand smoking by learning to crawl away (17). One’s initial reaction is incredulity of the message and then the necessity to share it with others. Using the television medium empowers the efficacy of the commercial to reach millions of people. Once very small children are affected, the message is much more effective.
Infect Truth is written at the end of each advert and manifests the advertising theory very successfully in the way the phrase is actually written. The word infect is in white and truth in black dots that seem to diverge. The point is to infect, or spread the contagious truthful knowledge. The promise behind this campaign is again infecting truth and spreading knowledge such that the promise of keeping children from smoking is realized and executed. The fact that these scenes are filmed in public places where ordinary citizens are allowed, even subtly encouraged to participate is key to the slogan. These people are spreading the contagion of knowledge by reading the messages (in Baby Invasion) or listening to the teenagers (Box of Poison, Sunny Side of Truth) and their very reactions cause teenagers’ perceptions to shift even more so because they see on national television that others are appalled and/or disgusted by the newfound information. These adolescents would therefore be more inclined to pay attention to the adverts from these reactions as well.
“The Truth” adverts, as myriads of studies have attested, are the only ones that make a positive dramatic impact on the perceptions and attitudes of teenagers. It is imperative to keep the focus on decreasing the prevalence of youth smoking. Although the Truth campaign’s funding was officially cut in 2003 by the tobacco industry because the latter lost its 99.05% market share, new adverts have begun to play again. The Citizen’s Commission to “Protect the Truth”, the only independent national youth counter-marketing campaign with demonstrated results in keeping children and teens from smoking, is demanding that the tobacco firms resume payment because ending smoking by American children and teens is crucial to their health and cost of healthcare to our nation (11). Moreover, the adverts themselves, and the message implied, are very concise and factual. There is no attempt to mislead anyone, but only to “infect truth.”


REFERENCES:
1. New York Daily News. Australian Anti-Smoking Campaign draws howls as boy sobs for mommy. New York, New York. http://www.nydailynews.com/lifestyle/health/2009/04/04/2009-04 04_australian_antismoking_commercial_draws_-1.html.
2. American Cancer Society. Guide to Quitting Smoking. Oklahoma City, Oklahoma. Http://www.cancer.org/docroot/PED/content/PED_10_13X_Guide_for_Quitting_Smoking.asp
3. British Medical Journal. “Don’t Smoke,” Buy Marlboro. Washington DC: Public Medical Central. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1115680
4. Tate, Peter. The Health Belief Model Explained for Patients. EzineArticles.com.<http://ezinearticles.com/?The-Health-Belief-Model-Explained-for-Patients&id=411478>.
5. University of Georgia. Why Some Anti Smoking Ads Succeed and Others Backfire. ScienceDaily. 6. Phillip Morris. Think. Don’t Smoke Campaign. Http://www.youtube.com/watch?v=Bh8YMaO-wsQ.
7. American Legacy Foundation. Getting to the Truth: Assessing Youths’ Reactions to the “Truth” and “Think. Don’t Smoke” Tobacco Counter-marketing Campaigns. Washington DC: American Legacy Foundation. 2002. p.22
8. New York Times. When Don’t Smoke Means Do. Washington DC: The New York Times. http://www.nytimes.com/2006/11/27/opinion/27mon1.html.
9. American Legacy Foundation. Getting to the Truth: Assessing Youths’ Reactions to the “Truth” and “Think. Don’t Smoke” Tobacco Counter-marketing Campaigns. Washington DC: American Legacy Foundation. 2002. p.18
10. Spivak, Joel and Berman, Michael. “American Legacy Foundation Study shows Philip Morris Think. Don’t Smoke Campaign is a Sham.” Washington DC: Tobacco Free Kids. http:www.tobaccofreekids.org/Script/DisplayPressRelease.php3?Display=499&zoom_highlight=duplicity
11. Citizens’ Commission to Protect the Truth. Truth Campaign Can Save Half a Million Lives and Billions of Dollars. New York, New York. http://www.jointogether.org/news/yourturn/announcements/2009/truth-campaign-can-save-half.html.
12. Wikipedia Encyclopedia. The Truth Campaign.
http://en.wikipedia.org/wiki/TheTruth.com
13. Counsel for Amicus Curaie, National Campaign for Tobacco Free Kids. Columbia Expert Panel and the Florida “Truth” Campaign. Washington DC. http://www.lungcanceralliance.org/news/documents/ALFAmicusBrief2.pdf
14. The Truth Advertisement. Sunny Side of Truth. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/
15. The Truth Campaign. New York, New York
http://www.protectthetruth.org/truthcampaign.htm
16. The Truth Advertisement. Box of Poison. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/
17. The Truth Advertisement. Baby Invasion. Infect Truth Anti-Smoking Campaign. New York, New York. http://www.thetruth.com/videos/