Coca-Cola Promises Happiness, We Throw Fat At Your Face– Nathan Brooks

The Boston Public Health Commission’s “Don’t Get Smacked By Fat” Media Campaign

If you spent any time waiting in Boston subway stations in October or November of this year, you likely saw them – four advertisements featuring four different adolescents drinking from generic bottles of soda or sports drinks, each wincing as a large glob of yellow fat flew towards his or her face. The unsettling pictures were accompanied by the words “Don’t get smacked by fat” and “Calories from sugary drinks can cause obesity and type 2 diabetes”. The ads, which were supplemented by similar advertisements on local television and radio, directed viewers to the campaign’s website, www.fatsmack.org, where they could learn more about the connection between sugary beverages and obesity (1).

In recent years, obesity prevention has emerged as one of the nation’s most pressing public health concerns. The most current data show the national prevalence of obesity to be around 33%. Obesity-related conditions, including heart disease, stroke, and type-2 diabetes, are estimated to cost the US health care system $147 billion per year. There are also glaring racial and ethnic disparities in the prevalence of obesity: while all racial groups are experiencing increasing rates, the condition is most strongly affecting non-Hispanic blacks (44%) and Hispanics (38%), vs 32% of whites (2).

Childhood obesity is seen as a vital area for intervention, both because overweight and obese children tend to grow up to become overweight and obese adults, and because obese children are already at high risk of numerous health conditions. Nationwide, approximately 18% of all adolescents 12-19 years old are now obese (2). In Boston, the numbers are similar – anywhere from 15-25% of Boston Public High School students are obese, and up to 44% are either overweight or obese (3-5).

Consumption of sugar-sweetened beverages is believed to play a substantial role in the development of obesity, especially in youth. Recent data from the National Health and Nutrition Examination Survey showed that the top energy source for 2-18 year olds was sugar-sweetened beverages (narrowly beating out grain desserts and pizza) (6). Recent research has shown that children have a 60% increase in odds of becoming obese for each additional serving of SSBs they consumer per day (7). Consumption of SSBs has also been associated with numerous health problems in addition to obesity, including diabetes, hypertension, hypocalcemia, and decreased bone density in young people (8).

In recent years, the city of Boston has attempted to decrease consumption of SSBs by children and adolescents, most notably by banning the sale of these beverages in Boston Public Schools in 2004. This intervention may have achieved modest success – a follow-up study showed that SSB consumption among high school students dropped from 1.7 to 1.4 servings per day following the ban – but failed to significantly reduce SSB consumption or turn the tide against youth obesity (9).

The Fat Smack media campaign is one part of a multi-faceted, federally funded initiative called the Communities Putting Prevention to Work (CPPW) Obesity Prevention project. Using $6.4 million in funding from the CDC, the project’s goals are to: 1) Reduce consumption of SSBs through “an aggressive media campaign utilizing counter advertising and youth-driven social marketing”; 2) Provide increased opportunities for biking and walking throughout the city; 3) Increase access to fruits and vegetables, especially in the neighborhoods of Roxbury, Dorchester and Mattapan, and 4) Increase physical activity and physical education in public schools (5, 10).

The goals of the program are laudable, and the designers should be praised for recognizing the need to go beyond encouraging individual behavior change and focusing most of their resources on making changes to the environment in which people live. However, the media campaign to reduce SSB consumption suffers from several fatal flaws, and is unlikely to produce positive results, either on its own or as part of the larger campaign.

Critique #1: Inappropriate Reliance on the Health Belief Model (HBM): “If only they knew that sugary drinks were bad for them!”

The health belief model is one of the oldest and most widely used models for health behavior change. As an individual model of health behavior, the HBM relies on the assumption that people’s health decisions are the result of rational, cost-benefits analyses. According to the HBM, six constructs influence the decision to adopt or avoid a behavior: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy (11). The Fat Smack advertising campaign relies on the health belief model to its detriment. First, the campaign only partially addresses the constructs of the HBM. Secondly, and more importantly, the HBM is unlikely to effectively produce behavior change in adolescents, especially for a behavior that is driven by environment, social norms, peer interactions, habit, and marketing more than by rational individual decision making (12-14).

According to one of the Boston teens who helped design the campaign, “A lot of teens in Boston aren’t taught the important stuff. What I hear from my peers is, ‘You eat too much, you gain weight.’ But it can also be sugar-sweetened beverages (15).’’ The idea behind these ads, then, is to raise awareness of the link between SSBs and obesity and obesity-related illnesses, with the idea that if teens were more aware of the risks presented by sugary drinks, they would make a conscious decision to avoid them. The ads clearly address the several constructs of the HBM. By showing non-obese teens about to get “smacked with fat”, they try to send the message that anyone who drinks sugary drinks is susceptible to obesity. The text of the ads and the additional information on the website attempts to increase teens’ perceptions of the severity of the consequences of drinking SSBs. And the graphic, unpleasant imagery in the advertisement is meant to serve as a cue for action.

There are two overarching problems with the use of the HBM in this campaign. The first is that most people, and adolescents in particular, have very different ideas about the risks and benefits of an action than those held by public health professionals. While I found it rather difficult to find good data on adolescents’ current state of knowledge about the risks of SSBs, it seems likely that the average teen already has knowledge of the fact that these beverages contain sugar and aren’t terribly healthy (16). However, teens possess an inherent sense of vulnerability which has been described as “personal fable” – the belief that they are special and unique, and that things that affect other people won’t affect them (17). Thus, telling a teen that “A child’s risk of becoming obese increases by 60% with each additional sugar-sweetened beverage consumed daily” is meaningless because the average teen, even if he or she understands the statistic and believes it in general terms, will never truly believe that it could apply personally to him/herself. For example, a study evaluating the effects of a mass-media obesity prevention campaign designed for teens in the Netherlands found that, despite excellent exposure to the campaign and an increase in teens’ perception of the severity of the obesity problem, there was actually a slight decrease in teens’ perceived personal susceptibility to obesity 1(18).

Additionally, messages that describe the long-term health effects of drinking SSBs are unlikely to have any impact on teens. The Fatsmack website is loaded with statements like “Drinking large amounts of sugary drinks can increase the risk of developing Type 2 diabetes, heart disease, and gout” (1). Most teens would consider these to be diseases of the elderly, and not part of any immediate risk-benefit calculation. To the extent that adolescents do consider the risks and benefits of behaviors, the ways in which the behavior could affect their day-to-day lives is much more important than any ideas about far-away health consequences (19). Interestingly, the Fatsmack website contains a link to several videos made by teens as part of a video contest leading up to the current campaign (http://www.youtube.com/user/DrinkSugarFree). Many of these teen-produced videos do focus on the day-to-day, with teens talking about how soda can cause acne, or that drinking water instead will give you more energy and improve athletic performance. Inexplicably, these insights from the teens were dropped completely when the professional campaign was designed. In fact, the Fatsmack campaign contains very little, if any, information about the positive benefits of alternative behaviors, and thus fails to address the “perceived benefits” construct of the HBM.

Finally, by basing this campaign on an individual-level model of health behavior, the designers ignored the numerous social and environmental factors that drive SSB consumption. Studies of teen beverage consumption have shown levels of consumption to be associated with taste preference, availability of SSBs at home and at school, consumption by parents and friends, exposure to marketing and habit (12-14). The local environment plays a large role – teens who live in areas with more fast food restaurants and convenience stores and less healthy food outlets drink more SSBs, which is likely an important factor in racial disparities and obesity (20).

I recognize that this media campaign is only one part of a multifaceted project, and that many of the other components do attempt to address the environmental roots of obesity. Individual behaviors do matter as well, and it is not wrong that the media campaign should address individual behaviors as part of a wider campaign that also addresses structural issues. However, given the inapplicability of the Health Belief Model to changing adolescents’ health behavior, these ads are doomed to be ineffectual at best, and to possibly even contribute to widening health disparities, as the focus on individual decision-making facilitates blaming the individuals while downplaying environmental factors (21). The resources earmarked for the media campaign could have been better used either in agenda-setting for the environmental changes (imagine a poster featuring young people demanding that we provide them with a healthy environment in which to grow up to be their best), or by recognizing the tremendous role that peers and social norms play in the lives of teens by attempting to influence their beverage consumption by applying the social expectations theory.

Critique #2: Failure to Anticipate Psychological Reactance: “You can’t tell me what to do!”

On the fatsmack.org website, there is a link to a video made by the Boston Youth Media Council in 2010 (http://fatsmack.org/2011/08/meet-the-youth-media-council-aka-warriors-against-sugar/). In the video, a pair of teens stand at a table in the Boston Common on a hot day, asking passers-by if they would like a free drink. When the unwitting subject asks for one of the sugary drinks offered, the teens instead give them the “sugar equivalent” of the drink – in different instances it may be a handful of ice cream sandwiches, two cups filled with whipped cream, or a plastic bag filled with greasy fat.

While a couple of the passers-by are receptive to the message, many react with disgust and anger, especially when shown the bag of fat. “So are you guys handing out free drinks or not?” and “What the [bleep]?!” were some of the angry comments made by people before storming off. After one of these comments, one of the teens turns to the other and says “It’s just going in one ear and out the other. They don’t get it, but we’re trying our best”. Finally, one passer-by who must have been 13 or 14 years old (instructively, he was wearing a T-shirt emblazoned with the words “I Don’t Give A F@$%”) takes the cup of whipped cream they offer him, looks at them defiantly, and starts drinking it through a straw.

This video, produced as part of the run-up to the Fat Smack campaign, should have served as a valuable learning tool for the designers of the current campaign. If a majority of people are reacting to a campaign with anger, followed by denigration of the messenger and defiant behavior, something is wrong. If the goal of the campaign is to actually produce behavior change, then it’s not adequate to say, in essence, “we’re doing our best – these people just don’t want to do what’s good for them”. Instead, it is imperative to redesign either the message or the manner in which it is delivered so that it will make the recipients want to follow the advice, rather than rebel against it.

This brings us to a discussion of psychological resistance and the Fat Smack campaign. The theory of psychological resistance states that persuasive messages pose a threat to freedom by telling the recipient, either explicitly or implicitly, not to do something. Individuals faced with such threats to freedom experience strong urges to perform the forbidden activity, thus restoring their freedom (22). This phenomenon has been known to cause a boomerang effect in some public health campaigns, in which exposure to the message had the opposite effect of that which was intended (23). The Fat Smack campaign, by essentially telling teens to stop drinking sugary beverages, is posing a threat to teens’ freedom and thus runs the risk of inducing reactance.

Certain aspects of how a message is delivered will increase or decrease the level of reactance generated by the message. High threat messages using strong or intense language are more likely to induce reactance (23, 24). I believe that the Fat Smack advertisements qualify as high threat messages – the teen in the ad is basically experiencing a violent act (being hit in the face), and the written message is constructed in the imperative voice (Don’t get smacked with fat) and uses intense language (smacked, fat).

Reactance can be mitigated when there is perceived similarity between the communicator and the recipient (25). Teens should experience less reactance following a message delivered by other teens, compared to one delivered by adults, especially adults in positions of authority. While there is a mention on the fatsmack.org website that the ads were partially designed by teens, this is not evident to anyone viewing the print or television ads. An adolescent is present in the ads, true, but only as an unwitting victim – the message printed on the ads apparently comes from the BPHC, which teens would perceive as a group of authoritative adults, completely dissimilar from themselves.

Critique #3: Ineffective Counter-Marketing: “They promise happiness, we promise… not getting hit in the face with fake fat?”

Any serious attempt to affect teens’ consumption of soft drinks has to account for the powerful role that advertising and marketing play in teens’ beverage choices. According to the FTC, beverage companies spent over $500 million in 2008 marketing sugar sweetened beverages to adolescents (26). Television advertising remains a primary means of marketing – the average adolescent viewed 402 ads for juice, fruit beverages and sports drinks and 169 for carbonated drinks in 2010 (27) – but beverage makers use a wide variety of marketing techniques to promote their products and brands, including print ads, point-of-sale marketing, sponsorships, celebrity endorsements, product giveaways, and increasing sophisticated online marketing where youth are invited into virtual worlds centered around beverages and beverage brands (28).

Adolescents are especially susceptible to marketing for several reasons (29). Brands play an important role for adolescents engaged in the search to define their identities – drinking a Red Bull or a Gatorade helps to define one’s identity and connect the individual to other users of the same brand (30). Adolescents’ desire for acceptance by peers is addressed by marketing that implicitly promises things like popularity and attractiveness, and by endorsements by widely-admired celebrities. Marketers shape the images of their products to meet the core values important to adolescents.

The Fat Smack campaign, on the other hand, fails to offer anything to youth beyond the promise of avoiding negative health outcomes that most young people don’t believe will happen to them in the first place. Again, the teens who produced their own videos for the 2010 video contest seemed to have a somewhat better understanding of this idea than the designers of the campaign – two of the videos, for example, showed student-athletes showing off their muscles while talking about drinking water instead of soda (promising attractiveness), while another video showed a group of teens dancing while drinking water (promising fun). The advertisements for the Fat Smack campaign, on the other hand, fail to make any promises (other than not getting hit in the face with fat) or appeal to any of the core values of adolescents.

Even with better use of advertising theory, it would be extremely difficult for a short term, $1 million marketing campaign to compete with the ubiquity of SSB marketing. Another strategy, then, would be to attempt to deconstruct SSB marketing to make young people more likely to reject it. For example, the Truth campaign successfully applied this type of counter-marketing to cigarette advertising, depicting cigarette ads as manipulative and encouraging teens to cut cigarette ads out of magazines as an act of rebellion (30). The Fat Smack campaign does make an attempt to engage in this type of counter-advertising: in the section of the website entitled “Be Smart”, the campaign provides two pages of text informing teens about how they are targeted by SSB marketing, followed by a page of links to examples of marketing techniques, such as youtube videos of Sprite ads. The problem with this approach is that the counter-marketing attempt is just pages of dry text, and the SSB ads are then presented as-is without attempts at commentary or parody to expose them as manipulative. As a result, the Fat Smack website ends up just providing a free platform for some rather effective beverage ads (I actually found myself wanting a Sprite when viewing one of the ads).

Another key to effective health promotions marketing is to create a brand, or a movement with which young people can identify themselves. This was used successfully in the Truth campaign, as well as current anti-smoking campaigns such as The 84 (30, 31). The Fat Smack campaign makes a rudimentary effort to engage young people in some sort of movement, asking visitors to the website to sign a sugar-free pledge and encouraging them to be leaders by talking to their friends about SSBs. They even devised a name for the youth members of the advisory council – “Warriors Against Sugar” – but other youth visiting the website aren’t invited to also become Warriors Against Sugar. The website also offers youths who sign the sugar-free pledge the chance to win T-shirts, wrist bands and water bottles in a raffle. However, the gear isn’t shown on the website, so teens have no way of deciding if it looks cool or not. Also, an effective marketing campaign would involve getting as much exposure as possible for the branded gear – it should be given away to as many people as possible, rather than to only a few people via a raffle.

The “Change Starts With Us” Campaign – An Alternative to the “Fat Smack” Campaign Based on Marketing Theory

Imagine that you just walked into the Mass Ave Orange Line station. You notice a few new advertisements up on the walls. In the first, a diverse group of teens stands in front of a school. The text of the ad reads “We’re going to change the world. We’re going to change our communities. First, we’re changing ourselves”. Smaller text at the bottom of the ad invites you to “Learn more at changestartswithus.org”. Only after looking at the ad for a while do you notice that the teens are all holding reusable water bottles with the “Change Starts With Us” logo printed on them.

A little further down, you notice the second ad. Here, a group of teens is standing on a basketball court. A couple of the branded water bottles are visible in the picture. The text on the top of the ad reads “You say our generation is lazy and out of shape”. Further down, other text reads “We’re going to change your mind”. Again, text at the bottom invites viewers to visit changestartswithus.org.

In a third ad, a group of teens stands in a convenience store, flanked by shelves piled high with soft drinks and sports drinks. The text of the ad reads “We are more than consumers”. In the fourth and final ad, a group of teens stands in front of City Hall, under a message reading “We have a RIGHT to live in healthy communities”. These last two ads also invite viewers to visit the campaign website.

When you enter the website, a video starts to play. Over a background of music, the video cuts back and forth between several different groups of teens. Some groups are engaged in physical activity – one group is at the gym, another is on a basketball court. Other groups are engaged in community service – cleaning up a park, tutoring kids, building a house. In each cut, a different teen delivers a line:

- “We’re going to change the world”

- “It’s our time”

- “Yeah, there’s a lot of problems these days”

- “Nothing we can’t handle though”

- “We know that if we’re going to change the world, we have to be at our best”

- “So we’re changing the way we live”

- “Eating right”

- “Getting plenty of exercise”

- “Staying away from unhealthy food and drinks”

- “Making a difference in our communities”

- “We’re going to change the world”

- “Wanna join us?”

After the video, you enter the website proper. There are sections titled “who we are”, “join the movement”, “get swag”, “events” and “chat”. On the “who we are” page, you learn that this is a movement of Boston teens who are dedicated to changing the world and their communities. The language is aspirational but vague, allowing the reader to imagine just what kind of change he or she would like to create. You learn that as part of their movement for change, these teens are dedicated to transforming themselves through healthy living, which includes being active, eating well, and staying away from things like “fast food and sugary drinks – those things will just slow us down”.

On the “join the movement” page, teens select a user name that will let them get free stuff and interact with others on the website. They are also invited to join or create a chapter of Change Starts With Us at their school – those who do will receive support materials enabling them to start a student group dedicated to helping each other live healthier and work to improve their local communities. On the “get swag” page, teens can request free T-shirts, reusable water bottles, wrist-bands and pedometers featuring the Change Starts With Us logo. On the “events” page, teens learn about upcoming events, including a basketball tournament (click here to register your team!), a dance contest (click here to register!), and a park cleanup. A few months away, there is also a chance for leaders of school chapters to have breakfast with the mayor to discuss changes they’d like to see in the city. Finally, in the “chat” page, there is a facebook style wall for teens to post comments, pictures and videos.

How would this approach be different from the approach taken by the Fat Smack campaign? First, it makes absolutely no use of the Health Belief Model, or any individual-level model of behavior change. There are no attempts to make teens feel susceptible to disease or impress them with statistics, because as I discussed previously, such approaches are highly unlikely to work with adolescents. Instead, avoiding sugary beverages is offered to teens as part of a package of behaviors that is itself part of a larger movement toward self-transformation and societal change. This approach recognizes that teens’ decision making is heavily influenced by peer-group norms (32), and seeks to influence behavior at the group, rather than individual, level. By being asked to join a movement rather than simply change a behavior, adolescents are given an opportunity for acceptance and defining themselves (30). Importantly, the teens delivering messages in my advertisements are never alone, but are always seen as part of groups.

My approach is less likely to produce psychological reactance than the Fat Smack campaign for three reasons. First, all of the messages in my advertisements are being delivered by teens themselves, rather than by adult authorities. Similarity between the messengers and recipients should decrease reactance (25). Secondly, my campaign sells a package of behaviors as being desirable, rather than telling people to avoid one particular negative behavior – ideally, this would be seen as granting freedoms, rather than taking them away. Finally, by presenting my persuasive message as an invitation rather than as an imperative, my hope is that the message will be seen as low-threat rather than high-threat, also reducing reactance (23, 24). In a real-life application, of course, I would test my campaign with focus groups prior to its full-scale launch, to evaluate its potential for inducing reactance and make changes as necessary.

According to advertising and marketing theory, the key to a successful campaign is to work with the core values that the target audience already holds and create associations between those values and your product (33). The hypothetical marketing campaign described above taps into values of self-empowerment, optimism, hope, change and a bit of anti-authoritarianism. Change is clearly a core value that resonates with young people – just consider the 2008 presidential campaign. In today’s world, young people are hungry for reasons to be optimistic and hopeful, something that both Coca-Cola (http://www.youtube.com/watch?v=9dHOzw5KSlE) and Pepsi (http://www.refresheverything.com/) take full advantage of in their own marketing.

Marketing theory uses branding as a way to build accumulated awareness of the product and of the values associated with the brand (30). My alternative campaign would build the Change Starts With Us brand through well-established marketing practices such as giving out free, branded merchandise and sponsoring events such as athletic competitions and community service days. Regarding free merchandise, the goal would be to give out as much of it as possible, both to raise awareness of the brand, and to increase teens’ perceptions that many of their peers are involved. This would definitely be economically feasible using the $1 million budget that the Fat Smack was given. For example, a quick web search reveals that it would be possible to purchase a plastic water bottle with our logo on it for every Boston Public high school and middle school student for less than $20,000, which would promote both brand awareness and water consumption (34).

Finally, the marketing approach would allow us to create a movement that could be directed in numerous directions for future health promotions, as opposed to a one-time intervention addressing one specific behavior. Once a movement associated with the Change Begins With Us brand gained momentum, the possibilities for future directions would be nearly endless. Want to encourage teens to examine how sugary beverage marketers target them? Sponsor a video contest where teens create their own videos parodying SSB ads. Want to encourage physical activity? Sponsor a fun run, or a basketball tournament, or provide space for teens to blog about their own experiences with physical activity.

Finally, a key feature to the marketing approach is the ability to use the movement for agenda-setting. As I discussed earlier in the paper, this campaign is merely one facet of an obesity-prevention project that has several other components dealing with environmental factors. Addressing environmental causes of obesity is absolutely necessary to create real change, and, while it’s a good start, the 2 year, $6.4 million CPPW grant will not be close to adequate for restructuring our local environment. What is needed is long-term agenda setting and political pressure from the people in the affected communities, and a key outcome of the Change Starts With Us movement would be to politically empower adolescents to work for and demand change to create healthier communities for themselves.

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33)http://www.slideshare.net/mcmrbt/advertising-theory-299204

34)http://www.discountmugs.com/nc/sports-bottles/1028/20oz-soft-squeeze-sports-bottle.htm