Challenging Dogma - Fall 2011

Friday, December 23, 2011

Boston Combats Adolescent Obesity Through “Fat Smack” Campaign: A Critique – Alicia Charleston

Obesity in America and Boston

Adolescent obesity continues to be a growing problem in the United States, particularly among youth and adolescents. As childhood and adolescent obesity often leads to overweight adults, it is an issue that needs be addressed at a young age (1). The Center for Disease Control {CDC} estimates 12.5 million youth, ages 2-19, in America are obese (2). The city of Boston, Massachusetts is no different. In its effort to combat both obesity and type II diabetes, in 2011 Boston’s Mayor Thomas Menino with the Boston Public Health Commission introduced the “Fat Smack” campaign (3).

“Fat Smack” as a youth intervention

“Fat Smack” is a youth and adolescent centered campaign. In a city with 57,500 public school students (4) and roughly 40% are overweight or obese (3), an intervention to reduce this problem is necessary. For teens 12-19 years old, the American Heart Association recommends 4.5 teaspoons of sugar daily, but a 20-ounce bottle of soda contains almost four times that recommendation, 16 teaspoons (3). Each additional serving of sugary drinks increases the frequency of high Body Mass Index {BMI} counts. While soda consumption is not entirely to blame for the increasing prevalence of obesity, it is certainly a contributing factor (5).

Parents do recognize the need for weight management in their children but barely 50% of those surveyed felt confident in their abilities to change the behaviors of their kids. Parents indicated that the most important method of weight management is physical activity. However the elimination of soft drinks fell fourth on the list, after portion control and increased consumption of fruit and vegetables. The survey indicates that parents also need to be educated regarding consumption of sugary beverages (6), and “Fat Smack” should work to educate a more broad population. Mayor Menino hoped the campaign would stretch across all demographics, including parents and young adults to take responsibility in making healthier choices (7). “Sugar Smarts” was created to fill the gap between adolescents and parental knowledge (8).

The Boston Public Health Commission is following suit of other major U.S. cities with their anti-soda campaign. They are attempting to lower obesity in part through decreasing the amount of sugary beverages consumed. These unhealthy drinks not only increase ones likelihood at becoming obese, but also it takes away from the consumption of healthy beverages, like milk and water. The city of Boston took a step in 2004 to reduce consumption of sugary beverages by banning sales in public school vending machines (9), but there continues to be a rise in obesity. Rather than taking on all causes of obesity, like improved nutrition habits or exercise behaviors, the campaign focuses on a single action: decreasing the consumption of regular soda, sports drinks, sweet teas and other beverages with added sugar. Mayor Menino rolled out this aggressive campaign about a month before his policy to pull sugary beverages from municipal buildings went into effect.

“Fat Smacks” print campaign features four attractive, non-white, adolescents attempting to drink sodas or sport drinks but instead they get hit in the face by a yellow ball of a gel-like substance, presumably fat. The statement “Don’t Get Smacked by Fat. Calories from sugary drinks can cause obesity and Type 2 diabetes” accompany the pictures of adolescents. The advertisements are prevalent throughout public transportation in the city of Boston. Alongside the print campaign are television advertisements, radio and a social media campaign via Facebook encouraging teens to take the pledge to no longer drink sugary beverages.

The campaign attempts to send an important message to youth and adolescents that drinking sugary beverages can adversely impact one’s health, specifically through weight gain and increased risk of diabetes. However, the campaign as it stands is not effective. It first uses silly and unrealistic print ads to attract the population rather than appealing to the core values of the target audience. Second, it attempts to engage youth through a media campaign but it is falls short of creating a movement led by youth. In marketing to teenagers, the campaign should make a stronger effort to change social norms. Teens who associate with peers that engage in risky behavior are more likely to do so themselves (10). There also tend to be misconceptions about the percentage of people who do engage in such behavior. Accurate evidence about the local population’s actions would improve assumptions about the social norms (11). If adolescents had an accurate representation of the percentage of their peers who drink sugary beverages on a regular basis, they might be better poised to influence the social norm. Finally the campaign fails to address the socio-economic disparities that are prevalent throughout Boston.

Print campaign: “Gross”

It gets your attention, but does it make you give up your soda addiction? The recent “Fat Smack” campaign released by the Boston Public Health Commission shows adolescents who are hit in the face with airborne yellow blobs of fat while attempting to drink sodas or sport drinks. The campaign has been effective in getting the attention of the local population and has been discussed on blogs and local magazines (12, 13). However the attention does not come from the reduction of sugary beverage consumption, mostly the attention is because the campaign is “kind of gross” (12) and induces fear in young people (13). The rise in obesity is an ongoing concern and youth do understand that one must exert more energy than they take in. The campaign attempts to fill in the knowledge gap that sugary beverages also contribute to their calorie count (14). Since teens consume twice as much soda as they do milk, this surge in weight-gain is understood (3).

The link between consumption of sugary beverages and weight gain is well documented. Specifically, it was found in a long-term study of female nurses that women who went from drinking one or less soft-drinks weekly to one or more daily documented weight gain as compared to women who did not. It was also noted that study participants who consumed greater numbers of sugary beverages were also less physically active and more likely to smoke (15). While it is clear that campaigns to reduce the consumption of sugary beverages are needed, there are better ways to raise awareness than throwing globes of fat at teenagers.

The “Fat Smack” campaign is relatively new, and long-term impacts of the campaign have not yet been reported. The campaign is aimed at adolescents to attempt behavior change at a young age. Since overweight youth and adolescents are more likely to be overweight or obese adults (2), attempting to change behavior in school-aged youth is a promising start.

But instead of creating a youth movement empowering adolescents to take on the producers of sugary beverages, the campaign uses fear to show the risks of consuming sugary beverages. Based on the ads it appears that any consumption of sugary beverages will automatically make a person fat, rather than the idea of everything in moderation.

Inducing fear, rather than fostering self-efficacy, does not always give the desired response. The print campaign does not increase one’s knowledge of how much sugar is actually contained in these beverages. It does not help teens make the choice to consume less sugar in their beverages. Rather the scare tactic causes people to perceive greater susceptibility to the undesired outcome at hand (16). Instead of inducing fear of weight gain through silly advertisements; the print campaign should be modified to appeal to adolescents desire for freedom and making their own choices (17, 18). It should give people the option to choose what they prefer to drink, like a cup of soda or a cup of raw sugar, allowing greater ownership of their choice not to consume sugary beverages.

Social networking campaign expected to engage youth

“Fat Smack” is not limiting itself to the traditional advertising methods of print, radio and television. In an attempt to connect with the Internet generation, “Fat Smack” set up a Facebook page, where someone interested in taking the Free from Sugary Drinks pledge is able to do so. The page has 634 people who stated they ‘like’ the page (19). But for a campaign aimed at the roughly 630,000 residents of Boston (20), to only have 0.1% of the population recognizing the campaign on the networking website is not enough. Improved use of the site could influence a larger population of people by building on the Social Network Theory. It can be a powerful tool in changing an entire groups behavior rather than focusing on an individual, as the theory uses the groups one associates with, such as family, friends, classmates and co-workers, to influence one another (21). The theory has been applied successfully in weight loss programs and smoking cessation program, and could likewise be practical to reduce consumption of sugary beverages.

“Fat Smack” has some youth involvement, specifically the Youth Media Council. Prior to launching the print campaign, the group “Warriors Against Sugar” hit the streets of Boston to educate people about the amount of sugar in beverages. They lured in passer-bys by offering free drinks on a hot summer day. The beverages offered were Sobe, Twister, Sunkist and Arizona Iced Tea. Rather than actually passing out these sugar-loaded drinks, the clientele were offered the equivalent amount of sugar in pie, ice cream, whipped cream and breakfast cereal. They filmed the street campaign to use as a marketing tool on their blog, and it shows the public interest in the information. The peer group “Warriors Against Sugar” should be more active in the community to increase the success of social network theory as a useful tool in the campaign (3).

In addition to the improved social networking and youth-led movements, social norms will not change if the greater population does not follow suit. Looking at Diffusion of Innovations, theorized by Dr. Everett Rogers, the change will occur in three phases (17). The “early adaptors” will initiate the behavior change, followed by the vast majority of the population and finally the lagers will take up the change. “Fat Smack” has early adaptors, as seen by their Facebook status and youth group. But it is not until the idea “tips” (22) that the majority of the population follows suit. However, there is no easy way to predict when the tipping point occurs. The tipping point can be triggered by a single person and can be an overnight success. In the same respect, it can also take years for behavior change to occur. In order to increase the success of continuing to lower the amount of sugary drinks consumed by youth and adolescents, the early adaptors will need to continue to force the topic into the public sphere. Early adaptors continued efforts to decrease soda consumption combined with efforts of Social Learning Theory, Social Network Theory and improved marketing will change the social norms of sugary beverage consumption (23).

Inequalities in obesity across socio-economic and racial groups

There is a disparity in obesity when comparing populations from different socio-economic backgrounds. At-risk and low-income populations in the United States tend to have greater levels of obesity and type II diabetes. In Boston roughly 25% of Latinos and 20% of African-Americans in the area live in poverty compared to 7% of Whites (24). Hispanic boys and black girls are more likely to be obese than their white counterparts (2). “Fat Smack” does understand these disparities and targets their campaign to these high-risk populations, by working directly with them in youth councils and reproducing the advertisements in Spanish (3).

Despite the efforts to focus the campaign on the low-income populations, sugary beverages remain more affordable than their healthier counterparts. They can be less expensive and more accessible than more nutritious options. So regardless of one’s knowledge of the harmful health effects, the continued consumption is often a matter of affordability.

To increase consumption of healthier drink options, New York City suggested coupling education and public health campaigns with a restriction on food stamps, banning the purchase of sugary drinks with food stamps. Los Angeles county Public Health director and chair of the CDC Prevention’s Task Force on Community Preventative Services, Jonathan E. Fielding, stated that education alone is not enough to change behavior; incentives and disincentives need to be in place as well (25). Banning food stamp purchases of sugary beverages could potentially adversely impact behavior if the affected population sees the policy as a loss of freedom. Psychological Reactance Theory causes a person to do the opposite of what is being advised (26). In this instance, the campaign would want to continue to drink sugary beverages but would purchase them elsewhere. The negative reaction could be accounted for if the price of sugary beverages increased while healthier beverage options became more affordable, encouraging the purchase of healthier options for low-income people instead of restricting someone’s perceived freedom to drink a sugary beverage.

Improving the “Fat Smack” campaign

For behavior change campaigns to be successful, it is necessary to combine behavior change theories. To reduce the consumption of sugary beverages on a larger, long-term scale, the social norms need to be changed as well. Cigarette smoking in bars and restaurants has changed in the recent past as a result of combining behavior change theories and a constant battle by public health professionals and policy makers. To successfully change behaviors of consuming sweetened drinks, “Fat Smack” campaign leaders should look at modeling the anti-smoking legislation by combining numerous behavior theories.

Reduced sugary beverage consumption through social expectations

The campaign first needs to update the marketing strategy to something more realistic. Then the campaign should also better utilize the theory of social networking to influence behavior of the population. A good print campaign is not enough to do this, especially when there is the continued bombardment of advertisements by Coca-Cola, Pepsi and the like. The campaign should appeal to youth and adolescents through a marketing approach that appeals to teens freedom, ability to choose and giving the target population a sense of ownership over their choice to consume water and natural juices. The campaign should be framed in a way that teens will take the campaign seriously. In addition, “Fat Smack” needs to get on the media agenda and work to influence policy.

Childhood and adolescent obesity is a serious health concern, just as smoking and drug use is. It increases one’s risk of type II diabetes, heart disease, high blood pressure and cholesterol, joint problems, psychological issues associated with discrimination and poor self-esteem (2). It is well documented that consumption of sugary beverages can increase one’s risk of weight gain.

Common in public health interventions, self-efficacy is necessary for success. If a person does not think they are capable of doing what is being asked of them, they are unlikely to succeed. A weight-loss study demonstrated this when the intervention group had greater overall weight-loss compared to the control group. The intervention group received support through social learning (27). The theory is built around the idea that a person’s environment, their own self-efficacy and their behaviors influence actions. It also takes into account reciprocal determinism, where one’s behavior and self-belief influence one another (18). “Fat Smack” should use Social Learning Theory to change individual behavior, but as stated before, “Fat Smack” should simultaneously attempt to change the social norm.

Youth-led movement, modeled after Truth’s anti-smoking campaign

“Warriors Against Sugar” is a youth-led program that works with “Fat Smack” to educate and combat sugary beverage consumption in Boston. However, they have failed to gain the large following of youth to really impact behavior change. Following a large settlement by tobacco companies in Florida, the then governor earmarked settlement funds for a youth-focused anti-smoking campaign. The anti-smoking campaign in Florida, “Truth”, began in 1998 (28).

The most important aspect of the youth centered campaign is involving youth. “Truth” brought 500 youth together to discuss what they felt would be successful, and worked around their ideas. The campaign stayed away from negative or preachy messages and focused on the facts. They worked to not impede on the target audiences freedoms or pass judgment on their choices. The campaign also created a brand. They had a public relations tour hitting 10 cities and a “truth truck” that made stops at major concert venues, beaches and raves. The brand “Truth” gave the youth a sense of identity in a similar fashion to other major brands, like Nike (28).

“Truth” was found to have a substantive impact on lowered cigarette usage and intention to use among youth following implementation of the campaign (29). It was also suggested that these decreases in smoking among youth were more likely to carry into smoke-free adults. Modification of the “Truth” campaign to fit the anti-soda and sports drink campaign led by “Fat Smack” will likely have greater success than its current campaign. It is unrealistic for “Fat Smack” to have the same availability to funds, but they can use a similar model to better engage youth.

As stated before, “Fat Smack” does have some of the ideas from the “Truth” model in place. However, in order to be successful it needs to be scaled up. The youth focus group needs to expand and their ideas needs to be considered for marketing materials. “Fat Smack” also needs to build up their brand. At this early stage in the campaign “Fat Smack” is primarily a print campaign. Print campaigns, as a sole marketing technique, is not an effective mean of engaging youth. In order to connect with the targeted youth, the “Fat Smack” brand should “surprise and lead”(28) the audience. While the current marketing campaign does surprise people by a blob of fat striking a person, it is not something that leads the audience away from sugary beverages.

Increased costs of sugary beverages to reduce consumption

Scaring people into not drinking sugary beverages because of weight gain will not be enough on its own to change behavior. Making healthier drink options more accessible and affordable will help, as will increasing the price of sugary beverages. A five-phase study at Brigham and Women’s Hospital in Boston showed that education alone did not reduce consumption of sugary drinks. The hospital cafeteria enacted a 35% price increase on regular {non-diet} soft drinks and saw a 26% decrease in those sales. The hospital then implemented an educational component in addition to the price increase and saw an additional 10% drop in sales. Following completion of the educational program, the hospital decreased the price of regular soft drinks by 18% to test the effectiveness of the program. Despite the price drop of regular soft drinks, there was not an increase in sales (30). The study was completed on a small-scale looking at the cafeteria in a single hospital, and further research needs to be conducted to determine generalizibility. It does give reason to believe that the educational component of “Fat Smack” when combined with a price increase will reduce the overall consumption of sugary beverages.

Instead of merely increasing the prices of sugary beverages, enacting a national sales tax on these drinks is a preferred option. Forty states already have small taxes on such beverages, but New York and Maine have proposed even higher taxes. The tax will be a simple revenue generator for states, giving them opportunity to subsidize healthy food options. Taxes on tobacco and alcohol products have been effective, which gives reason to believe that taxes on unhealthy beverages will do the same (31).

Higher prices and introducing or raising taxes on sugary beverages will help to deter people from consuming the unhealthy beverages while bringing in revenue for the state at the same time. All of these tactics have been completed in other public health interventions and have proven successful. “Fat Smack” has already laid the foundation for a solid public health intervention to reduce obesity by involving youth and getting some media attention.

“Fat Smack” on its way

“Fat Smack” as a campaign to reduce consumption of sugary drinks in youth and adolescents is an important public health intervention, especially given the rise in childhood and adolescent obesity. The campaign has many good ideas, but in practice they are not effective. A campaign aimed at youth and adolescents should actively involve members of the target population, getting them to join the movement against unhealthy beverages. The campaign does have “Warriors Against Sugar” but they have been unsuccessful in increasing the size of the movement. The environments of public schools municipal buildings in Boston have already changed no longer allowing sales of sugary beverages in vending machines. However the most visible aspects of the campaign, print and television ads, have received little attention. And most of that attention comes from the campaign being “gross” rather than changing attitudes and behaviors regarding consumption of sugary beverages. At the very least, the campaign has gotten the public discussing the consumption of sugary beverages. The campaign is a step in the right direction, but more needs to be done if it is going to be successful in changing attitudes and behaviors about consumption of sugary beverages.


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3. Boston, Massachusetts: Boston Public Health Commission. 2011. Available at: Accessed December 15, 2011.

4. Boston Public Schools. Boston Public Schools at a Glance. Boston, Massachusetts: BPS Communications Office. April 28, 2011. Available at: Accessed December 14, 2011.

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22. Gladwell, M. The Tipping Point: How Little Things Can Make a Big Difference. Boston: Little Brown and Company, 2000, pp. 3-14.

23. Professor Siegel, M. Class Lecture. Advertising and Marketing Theory. Boston University. 27 Oct 2011.

24. Metro Boston Indicators Project. The State of Equity in Metro Boston. Available at: Accessed December 15, 2011.

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26. Professor Siegel, M. Class Lecture. Social Expectations Theory and Psychological Reactance Theory. Boston University. 17 Nov. 2011.

27. Bélanger-Gravel, A, G. Godin, L-A. Vézina-Im, S. Amireault and P. Poirier. The effect of theory-based interventions on physical activity participation among overweight/obese individuals: a systematic review. International Association for the Study of Obesity 2010;12, 430–439.

28. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

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30. Block, J., A. Chanra, K. McManus, W. Willet. Point-of-Purchase Price and Education Intervention to Reduce Consumption of Sugary Soft Drinks. American Journal of Public Health Aug2010: 100(8): p.1427-1433.

31. Brownell, KD., TR Frieden. Ounces of prevention–the public policy case for taxes on sugared beverages. N Engl J Med. 2009 Apr 30;360(18):1805-8.

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