Challenging Dogma - Fall 2011

Monday, December 19, 2011

A Critical Review of the Montana Meth Project – Stephanie Gonzalez-Vitale

Methamphetamine (meth) is a highly addictive, central nervous system stimulant that can be ingested orally, injected, snorted or smoked (1). Meth is illicitly synthesized in laboratories in the United States and also in foreign countries (2). Illegal short-term and long-term use of meth can have harmful health effects. Long-term use can lead to addiction and result in chronic health consequences, such as neurological disorders. Paranoia, hallucinations and delusions are all severe mental complications of long-term abuse (2). Furthermore, users who inject meth are at risk of contracting blood-borne infectious diseases through the sharing of needles, including HIV, hepatitis B and C. In addition, meth lowers inhibitions, which makes drug users more likely to engage in risky behavior such as unsafe sex, which puts them at risk for sexually transmitted infections (3).
Meth use was originally isolated in urban areas on the West Coast, but has spread to rural areas in Western, Midwestern and Southern states. Cities along the West Coast, including Seattle, San Francisco, and Los Angeles still have high percentages of meth use (3, 4). The National Survey on Drug Use and Health’s 2005 survey found that an estimated 4.3% of the United States’ population had tried meth at some point in their lives (3). However, the survey also indicated a downward trend in meth use among youth in recent years (3). Since meth is synthesized in underground locations, known as “meth labs” or “meth homes”, it is easily distributed to drug-seekers (1). This capacity of widespread distribution, the risk of addiction and harmful health effects, have caused meth use to become a serious public health concern (1 - 4). In recent years, many organizations and the US government have attempted to develop successful public health interventions to combat meth use.
The Montana Meth Project
The Montana Meth Project (MMP), created by Thomas Siebel, is an organization that launched an extensive meth prevention program, aimed at Montana teenagers, in 2005. Siebel created the organization with the intent to educate Montana teenagers on the dangers of meth. The primary objective of the MMP’s advertising campaign is to increase awareness of the consequences of meth use (5). The central component of the project is a series of graphic television advertisements that portray the lives of ordinary teenagers as they develop an addiction to meth. These shock-value advertisements cover a wide range of negative consequences of meth use, including death by overdose, deterioration of health, psychosis, self-reproach, and compromise of morality (6). These ads do so by depicting meth users as violent criminals, who commit robberies, in many circumstances against their own families (6). Mark Kramer summarizes these shocking ads, in his article in the Stanford Social Innovation Review: “The 30-second spots begin with an ordinary teen whom kids can relate to, and end by showing the badly scarred and disfigured ravages that come from using meth”(7).
Each advertisement depicts a teenager experiencing a meth-related downfall. In some cases, prostitution is depicted as a consequence of meth use. One ad shows a teenager, stealing his mother’s purse, at the same time as a voice-over calmly explains how he has always had a great relationship with his mother. During the voice-over, the mother enters the kitchen to confront him. He violently hits her, knocking her to the floor. She clings to his leg, begging him to stop, but he kicks her off and runs out the door ( The implication of this ad is this violence is the result of meth abuse. In addition to illustrating violent behavior, many of the ads include vivid images of what is termed “meth mouth”, a dental deterioration that is a consequence of long-term meth use.
The MMP has self-reported their success, claiming that since inception of the program in 2005, there has been a 63 percent decrease in teen meth use, 72 percent decrease in adult meth use, and 62 percent decrease in meth-related crime (9). The MMP’s alleged success at changing attitudes towards methamphetamine and reducing drug use has been disputed, most notably by David Erceg-Hurn, who questions the validity of the project’s initial research and accuracy of results in his article in Prevention Science (10). However, the majority of the public and the state government approves of the MMP. Based on the perceived success of the MMP, the campaign has been recently adopted by seven other states: Arizona, Colorado, Georgia, Hawaii, Idaho, Illinois, Montana, and Wyoming (9, 11). The MMP was described as the third most effective philanthropy by Barron’s, which is a financial review magazine (9, 11).
Despite the widely perceived success of the MMP, there are three principal reasons why this explicit advertising campaign is a flawed public health intervention. First, development of the MMP was based on incomplete, inaccurate research on the campaign’s target population of Montana teenagers. Second, the MMP’s fear-based advertisements trigger a psychological reactance, which induces behavior opposite of what is intended by the intervention. Third, the MMP inaccurately concludes, based on the Health Belief Model, that attitudes and beliefs towards meth can be changed through increased awareness of the risks of using this drug
Lack of Formative Research in Development of MMP
Formative research is essential for any successful public health campaign, because it provides invaluable knowledge of the target population (12). This is crucial for campaign development (13). Inaccurate formative research threatens the internal validity of a campaign. Erceg-Hurn critically examines the MMP’s research, primarily by evaluating the MMP’s methamphetamine use and attitudes surveys. These surveys are the primary pieces of evidence used by the organization to develop their intervention (10). There are several issues with the population of teenagers and adults sampled. First, these were given out over the Internet. This is problematic because Internet-users tend to be more affluent and have a higher-education level than non-Internet users (10). Second, close to 75% of the participants were female, whereas only 50% of the population in Montana is female (5,10). This gender discrepancy is problematic in epidemiological terms, because it is necessary for the population sampled to be as similar as possible to the source population, which is also known as the population of interest: the residents of Montana. This flaw questions the validity of the study findings, or how applicable these are to the entire state population. Erceg-Hurn argues that the survey design and administration decreases the generalizability of the findings (10).
Accurate information about the target population, gathered from formative research, is necessary for the message of health specialists to be beneficial. Atkin and Freimuth suggest that health specialists must study the data on the target population in order to relate to them better: “Health specialists are not always conscious of the fact that they differ substantially from their audiences in knowledge, values, priorities and level of involvement; therefore, they lack the perspective of the ‘average’ person” (14). The MMP did not gather adequate information about Montana meth-users and therefore were not able to create effective advertisements that the population was able to relate to.
Fear-based advertisements trigger psychological reactance
A second flaw in the MMP is the use of graphic ads, which trigger psychological reactance. Simply put, psychological reactance is an emotional response in opposition to a perceived threat to personal freedom (15, 16). Perceived threats to personal freedom include “pressure to change attitudes, beliefs, and/or behavior” (17). When a personal freedom is threatened, an individual experiences an emotional reaction in order to re-establish the endangered freedom (15,16). Reactance is problematic in public health interventions because in many cases it produces behavior that is the opposite of what was intended by the intervention, known as “boomerang effects” (15, 16). Examples of boomerang effects seen in public health are the lack of success with both adolescent drinking interventions such as the rebellion against the minimum drinking age (15).
Psychological reactance to food warning labels was illustrated in a 1998 study, whereby participants were randomly assigned to one of three groups: no label, warning-label and information-label. The participants of all three groups had the same full fat cream cheese product to taste-test. The warning-label stated: “In this product, 90% of the calories come from fat. Warning: The U.S. Surgeon General has determined that eating high fat food increases your risk of heart disease” (15,18). In contrast, the information-label simply stated: “In this product, 90% of the calories come from fat.” Bushman found that participants in the warning-label group were more likely to want to taste the full-fat cream cheese than participants in the information-label group, based on psychological reactance (15, 18). This is an impactful finding, because it demonstrates the impact of a few choice words in any public health promotion message. Furthermore, Bushman’s study relates to the MMP because it shows that warning an individual against the harmful consequences of meth will trigger reactance and could result in the individual using meth in order to re-gain the threatened freedom.
Erceg-Hurn strongly criticizes the MMP for inciting reactance, stating: “The campaign has been associated with increases in the acceptability of using methamphetamine and decreases in the perceived danger of using drugs”(19). He claims that evidence of reactance is seen in the project’s own findings, in the form of statistics showing increased approval of meth use (10). He states: “The MMP claim that their advertisements are perceived by teens as being credible and impactful. The campaign’s data only partially support such claims” (20). Perceived credibility of a campaign’s message is essential because without it, any hope of changing attitudes towards a health behavior is futile. Although almost all of the teens surveyed agreed that the general objective of the MMP was directly communicated in the ads, however, a large percentage of teens (40 to 50%) believed that the risks of meth use were exaggerated and lacked credibility (10). Erceg-Hurn further points out that a population at high risk for meth use, Native American teens, had a higher percentage of skeptics (75%) than overall population of Montana teens (10). These findings support psychological reactance theory and show that the MMP ads triggered oppositional attitudes among Montana teenagers.
Assumption that awareness of meth risks leads to behavior change
The third flaw in the MMP is the assumption that awareness of meth risks prevents teenagers from using the drug, which is a key aspect of the Health Belief Model (HBM). The HBM, originally developed in the 1950s, is an individual level model that posits health behavior is influenced by four factors: perceived susceptibility; perceived severity; perceived benefits of an action; and perceived barriers to taking that action (21) The MMP advertisements are based on the premise that when teenagers are presented with the consequences of methamphetamine use, they will make a rational decision not to use the drug. In other words, Siebel aimed to change teenage attitudes about meth use through education. The MMP website states: “Every day, people are faced with the decision to try meth. Many perceive benefits in using the drug, but little to no risk”(11). Siebel assumes that increased perceived susceptibility and severity will prevent meth use. However, as it has been documented through tobacco cessation attempts, awareness of the health consequences of smoking does not lead to behavior change (22).
The HBM is an individual-level model that assumes health behavior is a rational process, however, much evidence has shown that behavior is irrational and based on emotions. One example of the irrationality in health behavior is cigarette smoking initiation and continuation, despite being aware of the health risks associated with smoking (22). Another example, related to meth use, is shown in a study the found that primary motivation for meth use is enhancement of sexual pleasures (23,24). Health behaviors are complex and cannot be predicted simply through an individual-level model. Methamphetamine use is a complex health behavior that is associated with factors such as employment, education, and gender (10, 25). All of these external factors were not considered during the development and implementation of the MMP advertisement campaign.
Another theory that explains the ineffectiveness of health risk awareness in changing behavior is the concept of optimistic bias. (26, 27). Roughly defined, optimistic bias concerning personal risk perceptions is when individuals believe that they are less likely to be affected by negative health consequences than others (26). This concept has strong implications against the use of Health Belief model in public health campaigns because it shows that education about health risks does not increase perceived susceptibility. Many studies have examined the effect of optimistic bias on perceived susceptibility of the health risks associated with smoking. A general consensus of the studies is that smokers are aware of the health risks, however, they believe that they are at lower risk compared with other same-age smokers (26, 27). Optimistic bias can be applied to the MMP, which shows that teens may believe that they are not susceptible to the negative consequences of meth use as other drug-users are.

Proposal of an Alternate Methamphetamine Intervention:
There are several target sub-populations for this proposed alternate meth intervention. In general, the overarching target population will be composed of individuals at high-risk for methamphetamine use based on employment, gender, education-level, ethnicity, and history sexual-risk behavior. These categories of inclusion are social and environmental factors that influence meth-use (10). The first sub-population will be composed of rural, unemployed, lacking college-education, white males. The second target sub-population of this intervention will be Native American Montana teenagers (10). The third, and final target sub-population of this proposed intervention will be hetero- and homosexual males who have a history of high-risk sexual risk taking and meth-use (23, 24). The third target group will be identified through self-reported surveys at treatment facilities.
Develop intervention based on formative research
Target Population: In this proposed alternate methamphetamine intervention, formative research on the target population and meth industry will be thoroughly conducted. Formative research gives essential information on target populations. An example of formative research in this proposed intervention is knowledge of the extent of meth use among HIV men who have sex with men (23). This research is important because it will identity the motivations behind the use of meth. For example, a study found that general motivations of meth use among HIV positive men who have sex with men are that meth: (1) enhances sexual pleasure, and (2) helps cope with HIV positive status (23). Knowing these motivations will be helpful in creating an intervention that addresses the perceived benefits of using the drug.
The proposed intervention will begin with interviews of each target sub-populations. The interviewers will appear as a peer to find out the real emotional appeal of methamphetamines and develop an intervention that addresses these core attractions to the drug.
Defense: First aspect of support for this intervention is the success of Florida’s “truth” campaign. It was based on careful, systematic, formative research (22). Secondly, Michael Siegel stresses the importance of formative research in campaigns, especially among interventions involving men who have sex with men. He states: “A second failure of public health programs has been the inability to understand and acknowledge that for some gay men, it is the destructive nature of unprotected sex that motives and supports the behavior in the first place” (30). In this proposed intervention, the target populations will be adequately studied in order to understand all motivations behind use of the drug.
Instead of using fear-based ads, develop intervention that uses reactance in the opposite direction.
A central implication of psychological reactance for the public health practice is to develop an intervention that incites reactance to benefit the intervention. In this proposed alternate meth intervention, advertisements should be created so that they spark reactance, not towards the health messenger, but to the meth industry itself. This can be achieved by creating ads that depict the true villain in meth, as the industry, not the user. The central message of the proposed intervention will be: The meth industry is exploiting vulnerable populations forcing them to become addicted to meth for economic profit. In order to re-gain freedom, current meth users should seek help in quitting. The current MMP ads, attempt to portray the meth as a villain. However, this message is not clear because the ads portray meth users as criminals. The proposed message will be explicit, in portraying the meth industry as the villain. This would ellicit a similar, perceived threat to freedom. However the viewers will be motivated to re-gain their freedom by (1) not trying meth in the first place, and/or (2) becoming motivated to quit meth. In summary, the proposed intervention will create reactance in the opposite direction, which would cause current meth users to feel as though the meth industry is taking away their freedom.
Defense: Turning the Tobacco industry into the villain was successful for Florida’s “truth” campaign.
Florida’s “truth” campaign was a smoking cessation program that successfully incited psychological reactance against the tobacco industry by portraying them as a villain (22). A fundamental concept of Truth was to create a movement against the industry: “Attacking the duplicity and manipulation of the tobacco industry became “truth’s” rebellion”(29).
Changing attitudes about methamphetamines cannot be done through increasing awareness about the health consequences of meth use.
A major critique of the HBM is that it does consider social and environmental factors that influence health behavior (21). In this proposed alternate meth intervention, the campaign should focus on social and environmental factors that influence meth-use (10). A factor that must be seriously examined is the high prevalence of meth use in rural parts of the United States, especially in Southern and Midwest states. Accessibility of meth is a primary influencing factor in meth initiation and continued use. This proposed intervention should lobby the US government to create strict laws to limit access to chemicals found in over-the-counter products used to synthesize meth. The chemicals are ephedrine and pseudoephedrine, which are found in common cold and allergy medications (10). These laws on the sale of these chemicals will decrease the accessibility of meth because it will be more difficult to make and therefore more expensive to buy.
Defense: Erceg-Hurn suggests that the MMP was not responsible for the decrease in meth use among Montana’s population. He argues for an alternate hypothesis of the reported decrease, which involves the restriction of ephedrine and pseudoephedrine. He states: “An alternate hypothesis is that methamphetamine use may have reduced due to a decrease in the availability of the drug. In July 2005, strict laws came into force restricting the sale of cold medicines in Montana...” (28). This supports the proposed intervention because it shows that the intervention has a strong chance of being successful based on past successes.
The MMP is a flawed public health intervention. Although it is a self-proclaimed research-based campaign, it has serious issues with its development. Furthermore, it incites psychological reactance and falsely assumes that increased education about the dangers of meth will change attitudes and beliefs about the drug. This proposed alternate methamphetamine intervention is one that incorporates social and environmental factors when looking at the scope of the meth problem. Additionally, the MMP graphic ads are be replaced with ads that depict the meth industry as the true culprit in meth addiction, with the purpose of triggering reactance against the drug. Finally, the alternate intervention begins with adequate formative research to gain an understanding of the target population of meth use and what they need, want and desire from use of the drug.
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