The National Youth Anti-Drug Media Campaign, an Ineffective Intervention Program for Teen Prescription Drug Abuse – Sandra Armakovitch

Introduction

In 2010, 10.1% of adolescents (age 12-17 years) were current illicit drug users in the United States (1). After marijuana (7.4%), prescription and over-the-counter drug abuse accounted for most of the top drugs abused by teens (3.0%) (1, 2). For example, high school seniors reported that 8% had non-medical use of Vicodin and 5.1% had non-medical use of OxyContin, both common opioids prescribed for pain relief (2). Overall, prescription drug abuse is on the rise in the United States and compared to other illicit drugs there are perceived incentives for abuse among teens, such as its easy accessibility, low cost, and decreased perception of potential harm (3, 4). Of those adolescents who reported abuse of prescription drugs, 55% claimed that they were able to receive them from friends and relatives for free, 11.4% paid for the drugs, and 4.8% stated that they simply took them from friends or relatives without asking (1).

In response to the prescription drug abuse epidemic faced by adolescents and adults, the Obama Administration’s Office of National Drug Control Policy (ONDCP) initiated the 2011 Prescription Drug Abuse Prevention Plan (2011 Prescription Drug Abuse Plan). The universal goal of this plan is to reduce prescription drug abuse rates by 15% in 5-years, allowing an additional $200 million to be allocated in prevention and treatment programs during the 2012 fiscal year. The plan of implementation, focusing on opioids, is to have every state to monitor and track prescription drugs, increase assistance in helping Americans learn how to dispose of expired and unused drugs, and increase education for those who prescribe drugs. However, the plan also wishes to develop evidence-based media campaigns on drug abuse targeting parents and teens to educate them about the risks associated with prescription drug abuse (5).

However, haven’t there already been several similar evidence-based educational media-campaigns in the past that have approached the issue of prescription drug abuse in teens? One major anti-drug campaign the federal government and Drug Enforcement Agency has partnered with is the National Youth Anti-Drug Media Campaign (NYADMC), which has created the sub-campaigns “Parent. The Anti-Drug,” (The Anti-Drug) (6) and “Above the Influence” (Above the Influence) (7). If these previous national mass media campaigns had been successful, wouldn’t we have seen a decline in observed rates of prescription drug abuse among teens? If they had been successful, why would the ONDCP create a new prescription drug abuse plan this year? According to a study presented by Dr. Buvanendran at the October 2011 American Society of Anesthesiologists, recent public service announcement campaigns, such as those created by NYADMC, may actually have been ineffective for curbing prescription drug abuse among teens (8). Will the ONDCP’s amended plan continue to reflect the failings of past mass media campaigns in the fight against prescription drug abuse?

Reliance upon the Theory of Planned Behavior (TPB)

Many health and anti-drug campaigns, including “Parent. The Anti-Drug” and “Above the Influence,” have created their fundamental frameworks based upon the Theory of Planned Behavior (TPB) Model. TPB is utilized to understand factors that form an individual’s decision making process, with the most important fact being their behavioral intention. Behavioral intention itself can be predicted by an individual’s attitudes towards a subject, perceived subjective norms, and the individual’s perceived behavioral control (9). For example, TPB would predict that an adolescent who believes that illicit use of a prescription drug is safe and ethical, thinks others perceive it as acceptable, and feels the stimulant would improve his or her ability to control their behavior would have a stronger behavioral intent to use. Completion of the behavior, such as prescription drug abuse, would be dependent upon the individual’s self-efficacy, or “can I do it” (10, 11).

Based upon the observations made under the TPB to assess adolescent prescription drug abuse, the NYADMC and its affiliates perceived that the best way to cause a shift towards the desired behavioral outcome (safeguarding prescription drugs in the home and declined prescription drug abuse) was to expose parents and teens to abundant amounts of persuasive, evidence-based information about prescription drug abuse. This strategy is made apparent through websites related to “Parent. The Anti-Drug” (The Anti-Drug) and “Above the Influence” (Above the Influence) as well as associated multi-media advertisements (6, 7). The desired effect in using such educational exposures would be to see a shift in individuals’ attitudes towards the desired behavior outcome, their perception of how others in their social group view their behavior, and their perceived control in performing the desired behavior. Such a shift would have resulted in a stronger sense in behavioral intention for an individual to make a behavior change (9-11).

However, though it is clear that parent and teen exposure to “persuasive, evidence-based information” about prescription drug abuse in adolescents was increased during the associated multi-media campaigns, it is not clear that these efforts have caused a shift in behavioral intention or behavioral outcomes (1-5, 8). By relying upon the TPB to formulate a prescription drug abuse campaign, the creators have inevitably ignored other important other variables that impact an individual’s process towards behavior change. In other studies that assessed illicit prescription drug use though the TPB, they concluded that though an individual’s perceived attitudes, subjective norms, and behavioral control had some association towards their prescription drug abuse behavior, they were restrained from determining what other social factors may have been associated with the behavior outcome (10).

An issue associated to the framework of the TPB model is it assumes that the behavioral outcome is the direct result of a rational, linear decision-making thought process. However, people are not always rational and factors other than “persuasive, evidence-based information” may be the variables that truly cause an individual to make a behavior change. Such variables may include personal emotions, habits, and even differences between gender and race (12). For example, a recent study found that girls have a higher rate of prescription drug abuse than boys (13). Another study also found that prescription drug abuse was higher among white adolescents compared to racial minorities. This same study also found that social differences related to ethnicity and culture were associated to increased and decreased risks of prescription drug abuse among teens (14). Furthermore, the TPB model fails to clearly define the concept of perceived behavioral control, which may be altered based upon not only physical but emotional barriers, which are variant from person to person. Finally, because of its linear progression, the TPB fails to recognize the variance in time between an individual’s behavioral intent (perceived behavioral control and self-efficacy). It is possible that the individual’s perception personal behavioral control and intention will change over a period of time or in an instant. They may no longer have the means of self-efficacy or they simply will fail to further pursue the behavior change (12).

Because of the NYADMC’s adaption of the TPB in their prescription drug abuse multi-media campaigns directed towards parents and teens, they have failed to acknowledge and utilize several other social pathways that have influenced present behavioral outcomes. For example, the main goal of the “Parent. The Anti-Drug” campaign was to educate parents on how to safeguard the prescription drugs in their homes while educating their children about the dangers of prescription drug abuse. However, after searching the campaign’s website and reviewing recent multi-media advertisements, such as “All My Pills” and “There’s a New Dealer in Town,” there is no evidence of an advertisement or educational materials that give focus upon key social differences that may arise among parents of girls versus parents of boys, variance in family structure, and differences between familial cultural identities. By neglecting these specific aspects of human social life, the NYADMC may have inhibited the range of parents that will make a shift towards behavioral change solely based upon the information provided by the “Parent. The Anti-Drug” campaign (6). This also holds true for the “Above the Influence” campaign. The mission of this specific campaign in relation to prescription drugs is to urge teens to make a behavioral change against prescription drug abuse. Yes, once again, the NYADMC has ignored social variance in their advertising campaigns and in the information that is presented on the campaign’s website. Furthermore, the advertisements created under the “Above the Influence” campaign fail to be explicit in addressing the issue of prescription drug abuse among teens. Therefore, even though there is plenty of evidence-based information presented on the website and in advertisements, without specific inclusions of various social variables and explicit prescription drug advertisements, the purpose of the campaign is lost (7).

Misuse of Marketing Theories

In public health, mass media campaigns tend to be viewed as a main means of communication to the public that also allows a way to control the type and amount of information that is received by the public (15, 16). With successful manipulation of multi-media technology, public health professionals can develop effective campaigns that have careful understanding of the underlying determinants of health behavior that could potentially lead to desired health outcomes and behaviors, such as the decline in prescription drug abuse among teens (16). As we have seen with the “Parent. The Anti-Drug” and “Above the Influence” campaigns, many public health mass media campaigns that begin to utilize marketing theories will initiate campaign development based upon the factors of influence on individual behavior through the TPB model (16). Again, this includes an individual’s perceived attitude of the behavior, their perception of subjective norms, and their confidence in behavioral control and self-efficacy (9). However, as with the campaigns created by the NYADMC, many mass media and marketing campaigns in public health will also stop their development at this point, missing many other tools of marketing theory that should be used in order to expect a successful campaign (15, 16).

Marketing theory in a setting such as public health is defined as a program-planning process that uses concepts of commercial marketing to promote a voluntary behavior change while facilitating feelings of acceptance, rejection, modification, abandonment, or maintenance of the particular behavior by the target audience (15). The main goal of the “Parent. The Anti-Drug” was to have parents change their behaviors to better safeguard prescription drugs in their own homes while education their child about the dangers of prescription drug abuse (6). Again, the goal of the marketing in the “Above the Influence” campaign was for teens to resist or give-up prescription drug abuse (7). However, if the NYADMC followed marketing theory to create these mass media campaigns, why did they? Other than using a social science theory, like TPB, to better understand the influences on human behavior, there are other key components of marketing theory that are usually misunderstood or ignored in public health campaigns (15).

The first is the notion of exchange, which influences the voluntary behavior change. What the campaign must do is inform the target audience about offer benefits that the consumer truly values. This usually requires focusing upon the target’s sense of core values: freedom, love, and hope (15). Upon reviewing the television and print advertisements for the “Parents. The Anti-Drug” campaign, none of the advertisements attempt to target the values that truly matter: freedom, love, and hope for oneself or others. Instead, they try and invoke a sense of fear to frame prescription drug abuse as a public health problem. For example, the television advertisement, “Drug Dealer Testimonial,” is focused upon a “sketchy” drug dealer talking to the cameraman, stating, “Don’t blame me if your kids are getting high,” (6). This not only targets a sense of fear, it places blame for teen drug abuse on the parent, failing to empower them with a sense of hope and control that they need in order to make the desired behavior change. The same is true with the print ad titled, “There’s a New Dealer in Town,” which shows a bathroom medicine cabinet in a back alley. Fear and blame are once again placed on the parent (6). The “Above the Influence” campaign is now attempting to use some of these core values in a positive way, however, though denoted by the NYADMC as one of the means to combat prescription drug abuse among teens, it still does not have an explicit advertisement addressing the issue (7).

Other key marketing concepts that both the “Parent. The Anti-Drug” and “Above the Influence” campaigns fail to recognize is the idea of audience segmentation and marketing mix. The NYADMC separated prescription drug abuse’s target audience into two sections, parents and teens, but there is where the segmentation and specialization ends. Marketing theory further separates target audiences into groups of people with shared needs, wants, lifestyles, current behavior, and values that will make them more likely to respond similarly to public health interventions (15). Because of the flaws in the TPB model that fail to recognize other significant social factors, the NYADMC has failed to recognize these factors in the marketing techniques designed for both prescription drug abuse campaigns (12). It has already been found in other studies that prescription drug abuse is more prevalent in girls and whites (13, 14). There may also be differences in family structure and interactions in the rolls it plays on increasing or decreasing the risk of prescription drug abuse across cultures and ethnicities within the United States (14). Neither campaign recognizes these differences, instead, their ads tend not to be explicit towards any particular sub-group that would benefit more from the information being provided than another. Instead, they use a universal advertising approach under the framework of TPB: give as much “persuasive, evidence-based information” as possible and hope the target audiences voluntarily take the message for the correct behavior change.

Finally, competition is an additional tool that must be used in a mass media public health campaigns. A successful public health media campaign needs to answer competition questions that offer benefits that best distinguish healthy behaviors (proper safeguarding and use of prescription drugs) from other health behaviors in the public that the campaign is combatting (prescription drug abuse) (15). Though the “Parent. The Anti-Drug” campaign makes an effort through its website of informing parents of how to safeguard their prescription drugs in the home, it fails to distinguish this activity in the other components of its media campaign as a healthy and beneficial step in preventing prescription drug abuse among teens (6). In the “Above the Influence” campaign, its website distinguishes the risks of prescription drug abuse, but it does not explicitly state what changes in health behavior would be most beneficial for teens as opposed to abusing prescription drugs. The campaigns television ads, such as “Follow Your Heart,” do advertise that to live a healthy lifestyle, you should follow your own ambitions, but it does not distinguish this behavior as different or better than abusing prescription drugs (7). A successful media campaign targeting prescription drug abuse among teens needs to be explicit in its differentiation of better and healthier behaviors compared to the social norm perceptions of prescription drug abuse (it’s ok to use prescription drugs is the current social norm perception among teens) (8, 10).

People are Irrational: Psychological Reactance Theory and Optimistic Bias

Psychological reactance is an enduring trait that all people have that arises when a person’s freedom(s) is threatened or eliminated. In the realm of public health campaigns, when an individual perceives a suggested healthy behavior change as a threat to their freedom (“don’t smoke,” “don’t do drugs”), the person will attempt to restore their self-sense of freedom by exhibiting opposition to the suggested behavior change or by resisting the pressure to conform (17). Four measurable factors are associated with psychological reactance theory, which includes freedom of choice, conformity reactance, behavioral freedom, and reactance to advise and recommendations. These factors account for most of the variance we see in individuals’ reactions to health behavior changes (18). Within these four factors, a difference in levels of psychological reactance to behavioral freedoms and conformity have been found within different age groups where younger people (<30) display a higher level of psychological reactance than older people (>30). This particular study concluded that maturity that comes with life experience enables individuals to view fewer situations as freedom threatening (17). The success of a public health campaign in implementing a new health behavior change, such as safeguarding prescription drugs or proper use of prescription drugs, can be influenced by the theory of psychological reactance (17, 18).

The question is, did the NYADMC take into the consideration the possibility of psychological reactance in its implementation of the “Parent. The Anti-Drug” and “Above the Influence” campaigns? The answer is no, and not many public health campaigns do take this theory into consideration. As presented in a current study by Dr. Buvanendran and his colleges at the October 2011 American Society of Anesthesiologists meeting, media campaigns like the ones mentioned here by the NYADMC to discourage prescription drug abuse among adolescents actually have an opposite effect. With the increased amount of information that has been made available about prescription drug abuse through the “Parent. The Anti-Drug” and the “Above the Influence” campaigns, teens believe that the dangers and risks of prescription drug abuse are simply being overstated and are biased (8). Again, the basic framework of the campaigns being criticized here are based upon the beliefs in the findings of the TPB model and that people are logical enough to be persuaded simply by an influx of available “persuasive evidence-based information” about the dangers and risks of prescription drug abuse (9-12).

In order to prevent psychological reactance impacting a health campaign, the initiators need to avoid psychological reactance completely by acknowledging current attitudes in beliefs instead of changing them, the opposite is true of the TPB model (9-12, 17). If campaign initiators cannot avoid invoking psychological reactance, they can attempt to reduce it by making explicit statements, give the target audience a perception of choice in controlling the behavior, and justify the statements being made (17). However, by believing that providing parents and teens with “persuasive evidence-base information” is substantial in changing the attitudes and beliefs towards prescription drug abuse, the “Parent. The Anti-Drug” and “Above the Influence” campaigns are ignoring the principles regarding psychological reactance: it is a person’s idea of freedom to have certain beliefs and attitudes towards their behaviors, if you try and manipulate their attitudes and beliefs they will oppose the suggested behavior change (17, 18). Furthermore, neither campaign provides advertisements that are explicit towards proper safeguarding prescription drug techniques in the home (parents) or the dangers of prescription drug abuse (teens, Above the Influence) (6, 7).

To further hinder the success of these campaigns, people exhibit what is called optimistic bias in which many people will underestimate the risk of health-related problems in either the risk imposed on themselves or others. If perceived risk is an important precursor of behavioral intent and change, people who experience optimistic biases are less likely to make the desired changes presented in a campaign. Optimistic biases can arise because of one’s selective recall of behavior factors and practices that can reduce their risk rather than increase their risk, by lack of information about protective activities of others, and the failure to think about risk between oneself and others because of a lack of comparative information (19). For example, optimistic bias was not addressed in the safeguarding prescription drugs in the home during the “Parent. The Anti-Drug” campaign because television and print advertisements failed to provide information and examples about the proper practices of safeguarding prescription drugs in the home (6). It was also not addressed among teens in the “Above the Influence” campaign because the advertisements did not provide real-world comparisons for teens to emulate in regards to preventing prescription drug abuse (“Follow Your Heart,” “Lost,” “Squirrels”) (7). Once again, because the NYADMC failed to consider so many other social and psychological factors of human behavior that branch beyond the TPB model, the “Parent. The Anti-Drug” and “Above the Influence” campaigns could not be successful in combatting prescription drug abuse among teens regardless of how much factual information was presented or to which population it was presented to.

“Be the Influence,” a New Campaign Against Teen Prescription Drug Abuse

Drug abuse among teens in the United States is a growing problem and current campaigns, such as the “Parent. The Anti-Drug” and “Above the Influence” campaigns created by the NYADMC, have been able to do little in curbing this trend (2, 8). This may be in part to the issues addressed earlier in relation to reliance upon the TPB model as the sole framework for the multi-media campaign, misuse of marketing theories, and underestimation of psychological reactance and optimistic bias. The “Be the Influence” campaign will be a new multi-media approach in the fight against prescription drug abuse among teens that will target many of the failings created (and ignored) by the “Parent. The Anti-Drug” and “Above the Influence” campaigns of the NYADMC.

The mission of “Be the Influence” will be to empower teens, their friends, and family to be the guiding source of positive influences in their own lives and the lives of others, not prescription drugs. The campaign will use a mass media approach that will use marketing theories, social expectance theories, and research based upon prescription drug abuse (facts and risks) and social factors to promote health behaviors that emulate positive lifestyles and practices in regards to safeguarding and proper use of prescription drugs by changing the social norm surrounding the power of influence of prescription drugs. The campaign will create a series of television, print, and radio advertisements that will address different social factors related to prescription drug abuse and how to safeguard prescription drugs. The campaign will also have a website in which individuals can search for information about the dangers of prescription drug abuse, prescription safeguarding, narratives, and ways to influence others to live a healthy lifestyle (not just by saying, “don’t abuse prescription drugs”) based upon the social situations the individual may identify with (gender, race, child, parent, etc). The goal is to change the social norm that prescription drugs are a main influence in our lives with negative impacts to the norm that people are the main positive influences in our lives.

Marketing Theory in “Be the Influence”

The first step in a successful mass media campaign for “Be the Influence” will be to utilize the tools and strategies frame worked by marketing theory. Other studies have already found significant differences in the prevalence of prescription drug abuse of girls compared to boys (13) and whites compared to other races and ethnicities (14). Under marketing theory, a tool that is used is audience segmentation (15). Based upon information from other studies, marketing theory can develop specific media advertisements that not only target teens and parents (6, 7), but segregate them further into sub-groups based upon social factors such as gender, age, race, and cultural identities. If the target audience can more closely relate themselves as similar to the subjects and situations in the advertisement they will be more likely to respond to the intervention presented in “Be the Influence” (15).

In order to influence a voluntary change in behavior, “Be the Influence” marketing will also need to create a notion of exchange. By following the mission that being an influence is a positive message, media and marketing will be able to more easily address the values that matter to the target audience, freedom, love and hope (15). Prior campaigns have used scare tactics with negative messages to try and persuade people to make a behavior change based upon the rationale that prescription drug abuse is bad (8).

Advertisements will use singular stories and realistic plots to tell a story of how one can make the correct adjustments in their lives to become the influence over prescription drug abuse (prescription safeguarding, healthy activities, etc). Furthermore, the slogan and mission of “Be the Influence” will give individuals the sense of freedom and choice to live the way they want to live, suggesting that they can have control over prescription drugs, not the other way around. Finally, by offering public health recommendations in how to curb the trend of prescription drug abuse through the storylines of the advertisements, “Be the Influence” will also be able to compete against other subjective norms that exist about what a safe/unsafe health practice is regarding prescription drugs, another tool used in marketing theory (15). The website associated with “Be the Influence” will closely echo those strategies, stories, and recommendations illustrated through the advertisement portion of the media campaign with links to the stories, personal blogs, and interactive pages to enforce the idea that people are the influence, not prescription drugs.

Social Expectations Theory in “Be the Influence”

Human nature is composed of a social context where there is a complex web of interpersonal bonds between individuals in specific groups. Factors that compose the organization of a social structure include social norms, roles, ranking, and sanctions and it is these factors that influence the behaviors of a social group (20). Through media campaigns, such as “Be the Influence” we can manipulate some of the factors that impact social beliefs and behaviors (20). This is different from the approach taken by the NYADMC campaigns, which focused upon changing the attitudes and beliefs of individuals without further considering their specific social structures.

The main goal of “Be the Influence” is to change the social norm understanding of what is truly the influence in our lives. Currently the focus is upon how prescription drug abuse is a negative influence in our lives and how we need to safeguard ourselves from being subject to its influences. However, through the mass media campaign of “Be the Influence,” we can manipulate the social norm about influences, thus changing the general rules that are understood and followed within social groups that create specific attitudes and beliefs (20).

Furthermore, through a combination of marketing theories and the understanding of social expectations and social organizations, “Be the Influence” will be able to illustrate new concepts of roles and rankings in specific social structures so that teens and families will see that their personal influence will have a greater role and ranking in how their lives are lived than how the old social norm of prescription drugs as the influence dictated. The portrayals in the mass media campaign will be trustworthy and target the identified sub-group audiences to allow individuals to learn from modeling what the new expectations related to influential roles in their social organization will be: “I am the influence over me, not prescription drugs” (20).

Reduction of Psychological Reaction and Optimistic Bias in “Be the Influence”

While the success of other prescription drug abuse campaigns, such as those created by the NYADMC, were hindered by underestimation of psychological reaction and optimistic bias, both inherent psychological traits of people, “Be the Influence” will be developed to reduce psychological reaction and optimistic bias. By addressing the issue of social norm under the social expectation theory and through appropriate marketing, the campaign will not be threatening individuals’ current attitudes and beliefs. By changing the social rules, individuals can make choices as to what their attitudes and beliefs should be. By providing a freedom of choice, individuals are less likely to react negatively and oppose any suggested behavior changes related to prescription drug abuse (17). Also, by giving individuals the choice to become the influence, individuals are once again allowed freedom of choice in how they perceive they behaviors and how they may change to fit the new social norms (17, 18). Furthermore, by giving the message of “Be the Influence” through explicit messages that are further specified into groups based upon social factors, individuals will not feel that they are being manipulated and thus having their freedoms threatened (17).

Finally, optimistic bias can be controlled for in “Be the Influence” by taking three strategies into action. First, optimistic bias can be controlled in media by the presentation of a strong emphasis between behavior and susceptibility (19). For example, an advertisement message would reflect how choosing prescription drugs to be the influence, you are increasing your risk of prescription drug abuse. Second, bias can be reduced by presenting specific behavioral objectives of the campaign (19). This strategy would include providing information in advertisements and on the website about how individuals can choose to become the influence and gain control over prescription drugs by correctly practicing safeguarding techniques. Third, and finally, optimistic bias can be reduced by providing the target audience examples of the preventive actions of others (19). This will be done in “Be the Influence” through advertisement segments illustrating individuals who chose to be the influence over prescription drugs and what steps they took to get to that point.

Conclusion

Many campaigns have been created within the past decade in order to combat the crisis of prescription drug abuse among teens in the United States. However, as of 2010, prescription drug abuse is still on the rise and is the top drug chosen for illicit use by teens second only to marijuana (1, 2). This sparked the Obama Administration’s ONDCP to initiate yet another plan to target prescription drug abuse in America as recently as April 2011 (5). However, the question is raised of how likely will this new plan succeed if past campaigns with similar goals have failed in curbing the prescription drug abuse plan? After a critique of the NYADMC’s campaigns “Parent. The Anti-Drug” and “Above the Influence,” one can see that there were several flaws with the strategies and frameworks of the multi-media campaigns based on the reliance of the Theory of Planned Behavior model, misuse of Marketing Theory, and underestimation of possible psychological reactance and optimistic bias that would result from the tactics of both campaigns targeting parents and teens. “Be the Influence” will be a new mass media campaign that will effectively address the flaws of other similar campaigns by accounting for other known social factor influences found beyond the framework of the TPB model (10, 13, 14), by utilizing all tools of marketing theory, by attempting to reduce psychological reactance and optimistic bias, and by using the Social Expectance Theory in order to address the issues of current social norms. In its effectiveness, the main goal of “Be the Influence” will be to change the social norm that prescription drugs are the influence to people are the positive influence in how we live. This message will be displayed through a website and strategic advertisement segments that accommodate all of the social factors that truly influence how one decides to make a behavior change, in this case, a change that will finally impact prescription drug abuse.

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