A Critique of the National Breastfeeding Awareness Campaign: Three Ways in Which the Campaign was Flawed- Rachel Bernier

Introduction

Breastfeeding is increasingly regarded to benefit the baby, mother and society. Breastfeeding benefits are so apparent that Healthy People 2o1o prioritized increasing breastfeeding rates as one of their goals (1). Additionally, the American Academy of Pediatrics highlighted the benefits of breastfeeding in its policy statement, “Breastfeeding and the use of human milk”(2). Studies show that infants who are breastfed have fewer occurrences of infectious disease, obesity, asthma, and several other health related outcomes (2). Breastfeeding also benefits the mother. Mothers who breastfeed are more likely to have a longer duration of time between the births of their children. They tend to have decreased bleeding after giving birth and a decreased risk of breast and ovarian cancers (2). Breastfeeding mothers benefit society because they are not producing waste from formula containers and infants who are breastfed are sick less often, resulting in lower health care costs (2). Furthermore, when an infant is sick less often, parents miss fewer days of work since they do not have to stay home to take care of a sick baby (2). Ultimately, Wolf (2007) states, “Human milk is the ‘gold standard’ when it comes to feeding babies” (3).

The Office of Women’s Health, a branch of the U.S. Department of Health and Human Services, launched the National Breastfeeding Awareness Campaign (NBAC) in June 2004 (4) . The campaign’s goal was to target first time mothers and African American mothers and convince them to breastfeed their infant (4-5). The campaign, and more specifically the media outreach campaign, consisted of several public service announcements in the form of television advertisements, radio advertisements, and print advertisements. The advertisements can be seen on the U.S. Office of Women’s Health website http://www.womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign/#materials. The print advertisements displayed images of dandelions, ice cream or otoscopes and stated that babies should be breastfed exclusively for six months to reduce their risk of respiratory illness, obesity, and ear infections (4). The television ads showed either a pregnant woman log rolling or a pregnant woman riding a mechanical bull. The text on both television ads said “you wouldn’t take risks before your baby’s born, why start after” (4). The radio advertisements had two styles: a soul music song and a country music song (4). In each song, a man sang about the benefits of breastfeeding (4).

The NBAC intended to increase breastfeeding based on evidence suggesting healthier outcomes in breastfed babies, but the campaign had several flaws. First, the NBAC failed to address the barriers to breastfeeding that keep some mothers from breastfeeding their newborn baby. Second, the campaign did not address the fact that breastfeeding is not a social norm in this society, and is rarely portrayed in the media. Lastly, the National Breastfeeding Awareness Campaign did not deflect psychological reactance in their audience. The people used to deliver this message were not similar to the target audience.

Campaign did not address barriers to breastfeeding

The National Breastfeeding Awareness Campaign provided information regarding the many benefits of breastfeeding throughout their advertisements, but they failed to address the barriers to breastfeeding. Women may encounter several barriers, making breastfeeding difficult or inconvenient and this may cause these women not to breastfeed. A workplace that is not accommodating to breastfeeding mothers is an example of an environmental barrier that might discourage a woman from breastfeeding (5). A mother’s social group (family and friends) can be another barrier to breastfeeding if they are unsupportive of her decision to breastfeed (5). Since some women have difficulty breastfeeding, being surrounded by unsupportive people may discourage her from breastfeeding. Wolf (2007) states that the NBAC was not intended to be “supporting, or otherwise being sensitive to the concerns of women but rather an attempt to manufacture and exploit fear among pregnant women and new mothers” (3). The campaign provoked fear in women instead of addressing the barriers women may be facing.

Based on Bandura’s Social Learning Theory, public health campaigns must take into account the environment of the targeted individuals. The Social Learning Theory acknowledges that the environment plays a role in an individual’s decision to change a behavior or not (6). Moreover, the Social Learning Theory suggests that self-efficacy is a necessary component for a successful behavior change (6). An individual will not attempt a new behavior if they do not believe that they are capable of performing it (6). According to Grusec, people can gain self-efficacy “from observation of what others are able to accomplish” (6). However, women exposed to the NBAC were unable to achieve self-efficacy concerning breastfeeding in the workplace since the NBAC did not portray this in the ads. The NBAC failed to address the environment in the campaign and therefore mothers were unable to achieve self-efficacy.

Bronfenbrenner’s Ecological Perspective Theory also supports that it is critical to address the environment when trying to change a behavior (7 -8). This theory suggests that living conditions, neighborhoods and communities, institutions and social policies all play a role in one’s decision to change a behavior (7-8). The NBAC did not specifically influence multiple factors affecting a mother’s ability to breastfeed, specifically the workplace or social environment. A campaign that fails to address factors like the one’s included in the Ecological Perspective Theory will be unsuccessful in changing a behavior. The Ecological Perspective Theory shows that the NBAC campaign only focused on changing an individual’s “intrapersonal level factors” (8). The theory describes some of the intrapersonal factors as knowledge, attitude and beliefs (8). However, a crucial aspect of the theory is that a behavior is influenced by multiple levels of influence including not only intrapersonal level, but also interpersonal level and community level factors (8). The NBAC only addressed intrapersonal level factors (ie. Education) and therefore was unsuccessful.

Campaign did not address that breastfeeding is not a social norm

The National Breastfeeding Awareness Campaign was a media campaign, but it did not portray breastfeeding as a social norm or acknowledge that breastfeeding is not seen in the media in this society. The NBAC did not use any advertisements showing women breastfeeding, typical for today’s media. Television rarely depicts breastfeeding; babies are most often with a bottle. Many women feel uncomfortable breastfeeding in public because breastfeeding is not a social norm. Breastfeeding an infant can become quite challenging if a woman is uncomfortable to breastfeed in public. Since the NBAC did not acknowledge that breastfeeding is not a social norm in this society, the campaign was not as successful as it could have been.

According to the Social Learning Theory, people do what they see other people doing, often referred to as modeling (6). However, the NBAC advertisements did not actually depict women breastfeeding. Instead, the ads displayed women participating in log rolling, women riding a mechanical bull, and images of dandelions, ice cream and medical equipment (otoscopes). This campaign did not demonstrate the act that NBAC was established to encourage. This campaign suffered from this particular failure because people are likely to act in ways that they see other people acting. Since women are exposed to more images of babies being fed bottles than they are of babies breastfeeding, its sensible that breastfeeding is not more common. According to modeling, women who viewed the NBAC ads were more likely to ride mechanical bulls and participate in log rolling than they were to breastfeed (6).

Schultz et al (2007) suggest that social norms are an incredibly strong indicator of behavior (9). Many successful public health campaigns have recognized this and adopted a campaign method called social-norms marketing (9). Social-norms marketing campaigns work to impact the true social norms of a behavior instead of merely educating people on the benefits of the behavior (9). According to Schultz et al, people overestimate how common undesired behaviors are and they compare their own behaviors to those of their peers (9). Therefore, campaigns led by the social-norms marketing approach show people that a behavior is more common than they may have thought. This information causes people to be more likely to adopt the suggested behavior (9). However, the NBAC did not affirm breastfeeding as a social norm or convince people that it is more prevalent then they may think. Ultimately, the targeted women were unlikely to embrace the behavior of breastfeeding since they were not reassured that it was socially acceptable.

The Theory of Planned Behavior recognizes that people consider how they will be perceived by others before behaving in a particular manner (8). Not everyone supports breatfeeding, which is evident since it is not portrayed in the media and not always welcomed in public settings. Many women are influenced by the opinions that individuals in their lives hold concerning breastfeeding. According to the Theory of Planned Behavior, if these women do not feel that breastfeeding will be perceived positively by others, they will not breastfeed (8). The National Breastfeeding Awareness Campaign had insufficient results because their ads did not address this.

Campaign did not deflect reactance by having the message delivered by someone similar to the target audience

The National Breastfeeding Awareness Campaign’s goal was to increase the breastfeeding rates in first time mothers and in African American mothers (5). However, the advertisements did not suggest that these particular groups of women were the target of the intervention. When the recipient of a behavior change message believes that the message is threatening their freedom they display reactance and do the opposite of the message or merely ignore it (11). One way to avoid Psychological Reactance is by having the message delivered by someone with similarities to the recipient of the message (10-11). The NBAC’s advertisements were not delivered by a messenger similar to the target audience. The print ads were not even depictions of people, they were objects. The radio ads were delivered by singing men and the television ads were delivered by pregnant women partaking in strange activities. The NBAC did not display any breastfeeding mothers. Based on the Psychological Reactance Theory this may have caused reactance in the women viewing the ads and caused them to not breastfeed.

The Social Learn Theory also suggests that the role of the messenger is crucial (6). The theory acknowledges that the source of a message must be in some way attractive to the audience of the message (6). If the deliverer of the message is not attractive to the audience then they must possess a form of power that compels the recipient of the message to be interested (6). The audience will lack attention if a message is delivered without a powerful or attractive messenger. It can be argued that individuals are attracted in some way to people that have similar characteristic as themselves (12). Since the NBAC failed to use a source of the message that had similarities to the recipient of the message, the recipients were not receptive.

Additionally, individuals are more likely to try a behavior that they can picture themselves doing (13). This is referred to as self-referencing (13). Since the NBAC’s advertisements did not display breastfeeding women with similarities to the target audience, the target women were unable to self-reference. Because these women were unable to imagine themselves breastfeeding when viewing the ads, they were unlikely to breastfeed as a result of the ads (13). The campaign failed to include characters in the ads that the viewers could relate to, this was extremely apparent in the radio ads, which were sung by men.

The article “Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign,” suggests that the NBAC’s attempt to target African American women was unsuccessful (3). The campaign tried to target these women by using an African American woman in one of the television ads and by the genre of music in the radio ads (3). While the NBAC’s intention may have been the opposite, Wolf’s suggestions raise questions about stereotyping. Ultimately, the campaign would have been more successful if it had put in a much greater effort to learn about the culture of their target populations (11). If the NBAC researched the cultures of their target audience it would have been able to use people to deliver the message that were similar to the target audience, this would have deflected reactance (11).

Proposed Intervention

The National Breastfeeding Awareness Campaign had several flaws that reduced its success, but the motivation for the campaign was very important. The U.S. Office of Women’s Health was aware that increasing breastfeeding rates would benefit babies, mothers and society. According to Merewood and Heinig (2004), one goal of Healthy People 2010 was for 75% of mothers to initiate breastfeeding and for 50% of mothers to breastfeed their baby for six months (5). However, the NBAC was not able to increase the breastfeeding rates to the desired values. A more thorough intervention will need to be designed in order for breastfeeding rates to increase in the targeted population, striving for the Healthy People goal.

In order to reach women who were uninfluenced by the NBAC, a new intervention will be designed to promote breastfeeding in first time mothers and African American mothers. The new intervention will be multi faceted with the goal to provide mothers with the necessary support, education and convenience that is needed to breastfeed. One aspect of this intervention will be implemented during prenatal care and early pediatric doctor’s appointments. This will offer women a way to obtain knowledge concerning the importance of breastfeeding and the technical support to breastfeed successfully. The mother’s primary support group (family and friends) will also be educated at these doctors’ visits so that they can offer the breastfeeding women as much support and encouragement as possible. Additionally, mothers will be provided with a peer-support group of other breastfeeding women. The new campaign will also include workplace policy changes to make breastfeeding more convenient for working mothers. Furthermore, the new campaign will use advertisements depicting breastfeeding women. Each aspect of the new campaign will help the campaign be more successful than the NBAC.

Addressing Environmental Barriers to Breastfeeding

The National Breastfeeding Awareness Campaign was flawed in that it failed to address the barriers to breastfeeding, but this will be fixed in the new intervention. The new intervention will provide benefits to workplaces that accommodate breastfeeding mothers. Based on the Social Learning Theory, if there are environmental barriers to a behavior, individuals will not do this behavior (6). This suggests that barriers to breastfeeding in the workplace must be eliminated in order for working mothers to breastfeed. By offering benefits to employers that make the workplace conducive to breastfeeding, working mothers will realize that they are able to breastfeed and work. This realization or feeling of self-efficacy is highlighted by the Social Learning Theory as a necessary component for an intervention (6).

Similarly, family and friends can act as barriers to breastfeeding for some women. The NBAC did not educate the family and friends of a breastfeeding mother about the importance of being supportive. As described by the Ecological Perspective Theory, behavior is influenced by family, friends and peers (8). If a mother’s primary support group is not in favor of breastfeeding, why would the mother breastfeed? The new intervention will provide the mother’s support group with an educational experience to help them support the breastfeeding mother. This will occur during the doctor’s visits. Once these people learn about their role in the breastfeeding process, they will be able to support the mother and breastfeeding will be more successful. Ultimately, the new intervention will aim to eliminate barriers to breastfeeding in both the workplace and in a mother’s social environment.

Campaign will aim to make breastfeeding a social norm

The new intervention will strive to make breastfeeding a social norm in this society since the NBAC did not do so. According to the Social Learning Theory, people model the behavior that they see others doing (6). The NBAC did not model breastfeeding in any of the advertisements, which made women unlikely to breastfeed. The new campaign will accomplish modeling by including television advertisements that display mothers breastfeeding in various locations, for example in a restaurant, at home, on a bus, etc. By displaying mothers’ breastfeeding in the ads, mothers will see that it is socially acceptable to breastfeed, even in public. Also, the media will be urged to show breastfeeding as opposed to bottle feeding in movies, television shows and in commercials. The campaign will offer increased air time to media companies that incorporate breastfeeding. This will increase the frequency of breastfeeding modeling that women are exposed to.

Additionally, the NBAC did not acknowledge that free formula is distributed by maternity clothing stores, hospitals and formula companies. This undermines the social norm of breastfeeding, making formula seem more popular. Schultz et al (2007) state that people overestimate how many individuals partake in an undesired behavior (9). Schultz et al would argue that women believe that breastfeeding is less common than it really is and by dispensing free formula this idea is reinforced (9). The new campaign will discourage hospitals from providing free formula to mothers unless a mother and physician decide together that breastfeeding is not best in her particular situation. Mothers will believe that breastfeeding is common if free formula distribution is reduced.

Furthermore, the Theory of Planned Behavior suggests that people consider how they will be perceived by others before deciding to act themselves (8). Since the NBAC did not strive to make breastfeeding a social norm, women were unaware of how individuals would perceive their decision to breastfeed. The new campaign will make breastfeeding a social norm and therefore women will be more reassured that if they breastfeed, others will support their decision.

Campaign will deflect reactance by having the message delivered by someone similar to the target audience

The National Breastfeeding Awareness Campaign failed to use a source of the message that had similarities to the recipient of the message. The implications for this were that the lack of similarity induced reactance to the message (11). Silvia (2005) conducted a study in which he found that when the communicator of the message is dissimilar to the recipient of the message, there is a “boomerang effect” (11). This suggests that people did the opposite of a message since the message was not delivered by someone similar to themselves (11). Additionally, if the audience can not relate to the messenger, the individuals targeted by the campaign are unable to self-reference (13). However, the new campaign will include a peer-support group, which will allow women to learn about the importance of breastfeeding from their peers. Women who take part in a peer support group will be able to interact with other women who have actually breastfed. The peers could be neighbors, co-workers or friends. Women interacting with their peers while learning about breastfeeding will be more likely to comply with the message (11).

Additionally, having a group of peers who are also breastfeeding mothers will allow the target audience to engage in self-referencing and imagine themselves breastfeeding (13). Burnkrant and Unnava (1995) state that self-referencing can be accomplished in a campaign that “addresses the audience directly and introduces experiences to which it can relate” (13). Not only will these women be able to self-reference as a result of the peer group, they will also become aware of the commonality of breastfeeding. While the NBAC did not deliver the message of their campaign by someone similar to the target audience, the new intervention will do this through the use of peers. Since the peers will share similarities with the targeted mothers, they will be able to contribute experiences that the targeted mothers can relate to. This will ultimately work in a persuasive way to promote breastfeeding and increase compliance (13).

Conclusion

The suggested intervention will be more successful than the National Breastfeeding Awareness Campaign in increasing breastfeeding rates because it takes into account flaws of the NBAC. First, many women face barriers to breastfeeding including lack of support from friends and family and also unaccommodating work environments. The new intervention addresses the environmental barriers in order to increase one’s feeling of self-efficacy (6-8). Second, breastfeeding is not a social norm in the United States society. The new intervention works to make breastfeeding become a social norm so people do not worry about how they will be perceived by others when breastfeeding (6-7). Also, people model the behavior they see; by seeing breastfeeding more often women will be more likely to model this behavior (6-7). Lastly, people are more likely to adopt a behavior change that is suggested to them if the message is delivered by someone similar to the recipient of the message (10-11). The new intervention recognizes this and delivers the message through peers. Using peers also allows mothers to self-reference and imagine that breastfeeding is something they are capable of doing (13).

The new intervention will incorporate improvements making it more successful than the National Breastfeeding Awareness Campaign’s attempt at increasing breastfeeding rates. The NBAC had several flaws that are corrected for in the new intervention and some of these concepts are recognized by the American Academy of Pediatrics (AAP) in its policy statement, “Breastfeeding and the use of human milk” (2). The AAP recognizes that a campaign’s promotion of breastfeeding must encourage breastfeeding to be a “cultural norm” (2). They also state that breastfeeding must be supported by families and society (2). The AAP believe that employers must provide “appropriate facilities and adequate time in the workplace” for breastfeeding mothers (2). Based on these recommendations by the AAP, it is clear that the National Breastfeeding Awareness Campaign was not sufficient in promoting breastfeeding. However, the proposed campaign recognizes the necessary aspects of breastfeeding campaigns as described by the AAP, and therefore will be more successful than the NBAC.

References

1. Healthy People 2010. 16 Maternal, Infant, and Child Health. Available at: http://www.healthypeople.gov/2010/Document/HTML/Volume2/16MICH.htm#_Toc494699668. Accessed December 10, 2011.
2. Section on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics. 2005;115(2):496 -506.
3. Wolf JB. Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign. Journal of Health Politics, Policy and Law. 2007;32(4):595 -636.
4. U.S Department of Health and Human Services. National Breastfeeding Campaign | womenshealth.gov. Available at: http://www.womenshealth.gov/breastfeeding/government-in-action/national-breastfeeding-campaign/. Accessed December 2, 2011.
5. Merewood A, Heinig J. Efforts to Promote Breastfeeding in the United States: Development of a National Breastfeeding Awareness Campaign. Journal of Human Lactation. 2004;20(2):140 -145.
6. Grusec JE. Social learning theory and developmental psychology: The legacies of Robert Sears and Albert Bandura. Developmental Psychology. 1992;28(5):776-786.
7. Bronfenbrenner U. The ecology of human development: experiments by nature and design. Harvard University Press; 1979.
8. Glanz K, Rimer BK. Theory at a glance: A guide for health promotion practice. Second Edition. U.S. Department of Health and Human Services, National Cancer Institute
9. Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ, Griskevicius V. The Constructive, Destructive, and Reconstructive Power of Social Norms. Psychological Science. 2007;18(5):429 -434.
10. Dillard JP, Pfau M. The persuasion handbook ... - James Price Dillard, Michael Pfau - Google Books. Available at: http://books.google.com.ezproxy.bu.edu/books?hl=en&lr=&id=lsF8zLomQOoC&oi=fnd&pg=PA213&dq=psychological+reactance+theory&ots=3-xUb5C0DO&sig=Y87th9UAemibPALaciQYP8bLPTU#v=onepage&q=psychological%20reactance%20theory&f=false. Accessed December 2, 2011.
11. Silvia PJ. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology. 2005;27:277-284.
12. Griffitt W, Veitch R. Preacquaintance Attitude Similarity and Attraction Revisited: Ten Days in a Fall-Out Shelter. Sociometry. 1974;37(2):163-173.
13. Burnkrant RE, Unnava HR. Effects of Self-Referencing on Persuasion. Journal of Consumer Research. 1995;22(1):17-26.

D.A.R.E.’s Failed Attempt to “Just Say No”-Sarah Doersam

Young adults in today’s generation are exposed to drugs, gangs and violence in a variety of ways; from what they see on television ads to what they are taught in their school systems. The way they choose to respond to the information they are given also varies in multiple ways, depending on factors from their environment to their personal behaviors. In today’s society, where teens have access to any type of information they desire, it is imperative that public health officials are successful in relaying and delivering their desired message to young adults (undoubtedly a complicated task). A major ineffective public health intervention that was implemented in the 1980s and 1990s to keep young adults off of drugs and away from gangs and violence is the D.A.R.E. program (Drug Abuse Resistance Education) (see Figure 1).

Figure 1.

The D.A.R.E. program, founded in 1983 in Los Angeles, is a “drug resistance education” program taught to young adults from kindergarten to the 12^th grade, and was implemented in 75% of American school districts and in more than 43 countries around the world (1). The program was led by community police officers, who taught a series of lessons inside school classrooms about how to resist peer pressure and “live productive drug and violence-free lives” (1). According to the D.A.R.E. website, “millions of school children around the world will benefit from D.A.R.E.; the highly acclaimed program that gives kids the skills they need to avoid involvement in drugs, gangs, and violence” (1). Students who enter the D.A.R.E. program sign a pledge to never use drugs or join a gang after the ten-week curriculum. To date, this program has failed to meet federal guidelines that the program be both research-based and effective, disqualifying them from eligibility for receiving federal grant money. According to the Center for Disease Control and Prevention, throughout the 1990s (at the height of the D.A.R.E. campaign) marijuana, cocaine, methamphetamines, and steroid use all increased in students in 9^th to 12^th grades (2). Unfortunately, the D.A.R.E. campaign failed to accomplish what it set out to do, and in fact during the height of its implementation, illicit drug use rates among young adolescents rose.

This public health program, intended to raise awareness, and in return decrease rates of drug use and gang participation failed on multiple levels. Despite annual spending of 1 to 1.3 billion dollars in 2001, the U.S. Surgeon General placed D.A.R.E. under the category of “Ineffective Programs”, and the Department of Education has prohibited schools from spending its “Safe and Drug-Free Schools” money on D.A.R.E. because of its ineffectiveness (3). In addition, multiple studies have been conducted refuting D.A.R.E.’s efficacy. According to a Time article, D.A.R.E.’s “goals include teaching kids creative ways to “just say no" to drugs, while simultaneously bolstering their self-esteem (which D.A.R.E. founders insist is related to lower rates of drug use). [According to Time] it's apparently not a bad way of educating five-year-olds about the dangers of drinking cleaning fluid. But it's a bust at keeping teenagers from smoking pot” (4). The article also found that D.A.R.E. status in the sixth grade was negatively related to self-esteem at age 20, indicating that individuals who were exposed to D.A.R.E. in the sixth grade had lower levels of self-esteem 10 years later (4).

Another study at the University of Illinois suggested that some high school seniors who’d been in D.A.R.E. classes were more likely to use drugs than their non-D.A.R.E. peers. More than 1,000 10 year-olds enrolled in D.A.R.E. classes were given a survey about drug use and self-esteem, and then, a decade later, the same group filled out the same questionnaire. Results from the study showed that 20-year-olds who’d had D.A.R.E. classes were no less likely to have smoked marijuana or cigarettes, drank alcohol, used "illicit" drugs like cocaine or heroin, or caved in to peer pressure than kids who’d never been exposed to D.A.R.E. (4). Researchers from this study also speculated that “by making drugs seem more prevalent, or "normal" than they actually are, the D.A.R.E. program might have actually pushed kids who are anxious to fit in towards drugs” (4).

Lynam et al. also conducted a study in 1999 that studied the long term effects of the D.A.R.E. program. The authors initially sampled a group of 230,000 sixth graders during the 1987-1988 school year in a Midwest metropolitan area. Data was collected before and after entry into the D.A.R.E. program, and follow-up questionnaires were collected from participants over a five year period when students were in the sixth to tenth grades. The 1, 002 participants (average age was 20.1 years) that were followed up with were sent a questionnaire asking about their use of alcohol, tobacco, marijuana and other illegal drugs. Results show the D.A.R.E. program had no effect on alcohol, cigarette, marijuana, or illicit drug use. Additionally, D.A.R.E. status had no effect on peer-pressure resistance levels, and D.A.R.E. status in the sixth grade was negatively related to self-esteem (5). Clearly, the program’s solution to “just say no” was an ineffective anti-drug message that wasted millions of dollars.

Theory of Reasoned Action

The multiple studies that confirm D.A.R.E.’s unsuccessful public health campaign to “just say no” prove that the intervention failed to consider, and appropriately apply several social sciences theories. First, the intervention failed to successfully apply the Theory of Reasoned Action. The Theory of Reasoned Action “suggests that a person's behavior is determined by his/her intention to perform the behavior and that this intention is, in turn, a function of his/her attitude toward the behavior and his/her subjective norm” (6). The Theory of Reasoned Action also holds that only specific attitudes toward the behavior in question can be expected to predict that behavior, and suggests that behavioral change ultimately is the results of changes in beliefs, and that people will perform a certain behavior if they think they should perform it. The D.A.R.E. program assumed that if they could change young adults’ beliefs about drugs, violence and gangs by telling them to “just say no”, they would be able to change their behavior and keep more adolescents off of drugs and out of gangs. This model is supposed to work on an individual level; it assumes individuals will rationally weigh their perceived outcome expectancies against their perceived subjective norms of changing a behavior (7). The campaign fails in that it does not consider the fact that people, especially adolescents, can act and behave irrationally. Although participants in a campaign, in this case a large population of adolescents, can be given accurate information and facts (drugs are bad, ect.), they sometimes do still participate in the wrong behavior. D.A.R.E. only offers its participants one solution concerning drugs, violence and gangs; to “just say no”, and they assume kids who participate will consider this to be a rational solution to drug abuse and resistance. D.A.R.E. does not consider that it is highly unlikely that adolescents will act “rationally” in every situation they come across where drugs, gangs and violence are involved.

The Psychological Reactance Theory

The Psychological Reactance Theory is defined as “an adverse affective reaction in response to regulations or impositions that impinge on freedom and autonomy and is especially common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior” (9). According to the theory, reactance “often encourages individuals to espouse an opinion that opposes the belief or attitude they were encouraged, or even coerced, to adopt” (9). The D.A.R.E. campaign never considered this possibility over their two decade run. “Reactance” occurs whenever a free behavior is restricted, and this is exactly what happened with this campaign. D.A.R.E restricted participants’ behavior with “just say no”, so many acted out and did exactly the opposite behavior D.A.R.E. intended. The program took away young adults’ freedom to make their own decisions about actions to take in peer groups and social settings, making adolescents try to re-establish their freedom by rebelling against the program altogether.

D.A.R.E. was not the only public health campaign that failed to consider the Psychological Reactance Theory; “Above the Influence”, a more recent anti-drug campaign, also unintentionally caused adolescents to rebel against the intended message. The Above the Influence campaign was created with the intention to target teens with anti-drug messages, primarily concerning the use of marijuana (10) (See Figure 2 below). Despite a great deal of funding provided by the government, Above the Influence, similar to D.A.R.E. failed to successfully influence teenagers not to abuse marijuana, or other types of recreational drugs. The advertisements created for this campaign told viewers that they must live “above the influence” or they would become just another statistic of a teen lost to drugs. By depicting teenagers who smoke marijuana as lazy and irresponsible, the campaign dissociated their target audience and caused them to rebel (as seen in many parody UTube videos). The campaign did not give teens a sense of control, and that loss of control and freedom was the primary instigator for rebellion, and a failed public health intervention. Because the campaign focused on how teens should not behave and what they should not do, many teens felt that their personal freedoms were threatened. Above the Influence failed to create a sense of identity for its target audience and, similar to D.A.R.E., only focused on restricting young adults’ behaviors. In a report released in 2006, the United States Government Accountability Office “did not find that the youth anti-drug media campaign was effective in reducing youth drug use” (11). The study found that that “among current, non-drug-using youth, exposure to the campaign had unfavorable effects on their anti-drug norms and perceptions of other youths’ use of marijuana- that is greater exposure to the campaign was associated with weaker anti-drug norms and increases in the perception that others use marijuana” (11).

Figure 2.

As demonstrated with the increase in recreational drug use trends during the 1990s, D.A.R.E. failed to successfully reign in its target audience; adolescents, again, reinforcing their failure to apply the Psychological Reactance Theory. The D.A.R.E. campaign tells its participants not to do drugs by unsuccessfully using police officers to deliver their message. Because the target audience is adolescents, the program should not have used a population (police officers) that is so different from them. According to a PBS released study, “the young adolescent brain works differently than an adult brain, and responds differently, especially in emotional situations, acts more impulsively and considers consequences less compared to adults” (12). Although the police officers may have taught accurate information about drugs, violence and gangs, they were unsuccessful in delivering their message because they do not easily relate to the adolescent population; their brains work differently. This sent the wrong message to teens that drugs are a law enforcement issue, not a public health issue.

Additionally, a police officer may “intimidate adolescents who have experimented with drugs from asking lifesaving questions out of fear that they would get into trouble” (13). Fear-based advertising “is a specific type of social marketing that employs scare tactics or other anxiety-producing mechanisms to highlight the dangers of engaging (or not engaging) in a certain practice”, in this case, teen drug use (14). This type of strategy was also implemented by the New York City Department of Health and Mental Hygiene with its anti-smoking campaign, “Smoking Kills” in 2009. The Department believed that by using graphic images smokers would become more aware of the health risks associated with the behavior and be influenced to quit (See Figure 3. below). Instead, when smokers saw the graphic images on the cigarette packages, they became stressed out and smoked even more, completely negating the purpose of the campaign. Similar to the failed “Smoking Kills” campaign, D.A.R.E. unsuccessfully used fear to try and implement their message to a target audience that was completely dissimilar to those who were relaying the message; causing the target population to rebel against the intended message.

Figure 3.

Optimistic Bias Theory

The D.A.R.E. campaign also fails to consider the Optimistic Bias Theory and its effect on adolescents. Optimistic bias is commonly defined as the mistaken belief that one's chances of experiencing a negative event are lower (or a positive event higher) than that of one's peers (15). This means that giving statistics and facts alone are not enough in public health campaigns; they need to tell a story and be able to capture the viewers’ emotion to be powerful and impactful. According to this theory, people do not believe their own risk of adverse behaviors is elevated. Weinstein (1980) demonstrated that “a majority of college students believed their chances of events such as divorce and having a drinking problem to be lower than that of other students, and their chances of events such as owning their own home and living past 80 years of age to be higher than that of other students” (15). The implementers of the D.A.R.E. campaign did not consider the fact that many adolescents feel like they are immortal and that nothing bad could ever happen to them (i.e. being confronted with drugs and potentially becoming addicted). Weinstein also says “It is possible to be optimistically biased by being overconfident about the objective chances of experiencing a positive event (or avoiding a negative event), irrespective of how one's chances compare with those of one's peers” (15). Again, D.A.R.E.’s failed campaign negated to consider vital Social Science theories.

Proposal for an Alternative Intervention

An alternative intervention to the D.A.R.E. campaign could show significant improvements in the campaign’s lack of beneficial results. By incorporating the appropriate Social Sciences theories and learning from what was unsuccessful in the old D.A.R.E. campaign, the new program can better organize and apply its approach. The new anti-drug campaign will be called “Dare to Dream and Succeed” and will incorporate, and appropriately use Advertising Theory, Psychological Reactance Theory and the Social Cognitive Theory.

Advertising Theory

Rather than using facts and figures to relay a public health campaign, an adolescent anti-drug campaign would be more effective if it was based on Advertising Theory. Advertising is a form of communication used to persuade its audience to take action in respect to products, ideas or services, and if appropriately used can be successful in public health campaigns. The “Dare to Dream and Succeed” campaign will advertize teen (the target audience) involvement in things other than drugs, like sports or clubs (anything that requires ambition and goal setting) and will use a messenger more similar to them, yet able to catch and hold a teenager’s attention; Justin Bieber. To make this advertisement successful, it will incorporate a promise, support, and core values. Justin Bieber will deliver a message that tells adolescents to follow their dreams by being involved in ‘healthy and safe’ activities so one day they too can be successful, and possibly even famous. The promise made in this advertisement will be that if you get involved in activities that support your long term goals (whether it be joining a team to be a professional athlete or joining the debate club to be a successful lawyer) you, like Justin Bieber, can be successful, happy, and potentially rich and famous (which is what will appeal to the target audience most). This promise is supported by Justin Bieber telling the target audience if they get involved in following their dreams and don’t allow drugs to get in their way, they can be like him. Also, this advertisement incorporates core values of hard work, dedication, attractiveness, money and success, which are ideals this audience values. A good public health campaign the “Dare to Dream and Succeed” can turn to is the Truth Campaign (see Figure 4 below).

Figure 4.

The Truth Campaign “is the largest national youth-focused anti-tobacco education campaign ever and is designed to engage teens by exposing Big Tobacco's marketing and manufacturing practices, as well as highlighting the toll of tobacco in relevant and innovative ways” (16). The Truth Campaign has been very successful in delivering their message; “seventy-five percent of all 12 to 17 year-olds in the nation - 21 million - can accurately describe one or more of the Truth ads, nearly 90 percent of youths aged 12 to 17 - 25 million - said the ad they saw was convincing, and eighty-five percent - 24 million - said the ad gave them good reasons not to smoke” (16). Thanks in large part to the Truth Campaign, declines in smoking rates among high school students has decreased by more than one million. This public health campaign has been so successful because of its effective use of Advertising Theory, and its ability to “capture the promotion of rebellion against the tobacco industry as a call to action to commit to a tobacco-free lifestyle” (17). The Dare to Dream and Succeed campaign, similar to the Truth Campaign, will not be a rebellion against abusing drugs, but call for a rebellion against unhealthy influences that get in the way of reaching your dreams.

Psychological Reactance Theory

This new campaign’s advertisement will target young adolescents though the Psychological Reactance Theory; understanding that a person will react to a perceived threat to their freedom when they are told what to do as well as what not to do. By turning the tables and delivering the message that drugs will take away your freedom to reach your dreams, teens will be more likely to rebel against experimenting with and abusing them. This new campaign will focus on positive messages; that by staying involved, you can reach your dreams. The Dare to Dream and Succeed campaign gives young adults a sense of ownership that they can reach their dreams, take control of their lives and make their own decisions, without the influence of drugs. This campaign can be successful if they follow in the Truth Campaign’s footsteps by delivering the message that the unhealthy behavior is what is taking their freedom away, and that is what teens should rebel against.

Social Cognitive Theory

The Dare to Dream and Succeed campaign will also be successful if it applies the Social Cognitive Theory. The Social Cognitive Theory defines human behavior “as a triadic, dynamic and reciprocal interaction of personal factors, behavior, and the environment” (18). This campaign will consider young adults’ environment, behavior, and personal factors and recognize that each person is different, behaves differently, and is in a different environment. Simply “just say no” cannot be universally applied to each individual and thought to be successful, so the new anti-drug campaign will equip its target audience with tools that can be used in a variety of environments and peer-pressure situations; the ability to recognize drugs are what will take away their freedoms. Because the new campaign offers young adults the opportunity to aspire to be something and to be involved with activities that lead them to their dreams, they have multiple reasons to not get involved with drugs.

According to the Social Cognitive Theory, a behavior change is “made possible by a personal sense of control”. When individuals have ownership in their actions (self-efficacy), they are more likely to adapt to positive health behavior changes (19). When young adults have ownership in something, they are more likely to make the decision to not do drugs. Having something they are involved with gives them an ownership over something that drugs would interfere with. Also, incorporating “modeling behavior” is essential when utilizing the Social Cognitive Theory. When a ‘model person’, someone that is similar to the individual, successfully masters a difficult situation, “social comparison processes can enhance self-efficacy beliefs”, and ultimately successful behavior changes; when young adults see their peers (and Justin Bieber!) making health choices not to do drugs, they will be more likely to do the same.

If Dare to Dream and Succeed can be turned into a movement, similar to “the 84” campaign, a successful public health initiative is much more probable. The 84 is “a youth led movement fighting for a tobacco-free generation in Massachusetts”, and has successfully marketed their organization into a movement (20) (See Figure 5 below). The “84” represents the 84% of Massachusetts teens who choose not to smoke, giving teens a positive association to be a part of. This movement is successful in that it, similar to the Truth Campaign, organizes teens to fight against the tobacco industry for trying to infringe upon their freedoms. The 84 successfully leads young adults in a rebellion against smoking, and a movement to “do positive things” (20). Dare to Dream and Succeed needs to implement the 84’s strategy of calling teens to join a movement to do “positive things”, and NOT to do drugs.

Figure 5.

Dare to Dream and Succeed’s campaign success is dependent on the incorporation of each of the previous models appropriately and in a cohesive manner. It is important that we look to the old D.A.R.E campaign to examine where and why it was unsuccessful, and learn from their mistakes. Impacting a teen’s behavior and decisions is not an easy task, but it is possible and has been done before with multiple successful public health programs like the 84 and Truth campaigns. If we can look to what is successful, learn from past mistakes and consider the implications of Social Science Theories, Dare to Dream and Succeed has the potential to join the ranks with the 84 and Truth campaigns as public health successes.

References

1. Drug Abuse Resistance Education. D.A.R.E official website. Accessed on December 2, 2011 at: http://www.dare.com/home/Resources/Default5647.asp?N=Resources&M=16&S=0.

2. The Center for Disease Control and Prevention. Trends in the Prevalence of Marijuana, Cocaine, and Other Illicit Drug Use, National YRBS: 1991-2009. Accessed on December 2, 2011 at: http://www.cdc.gov/healthyyouth/yrbs/pdf/us_drug_trend_yrbs.pdf.

3. Drug Policy Alliance, D.A.R.E. New York, NY: Drug Policy. Accessed on December 1, 2011 at: http://www.drugpolicy.org/library/factsheets/D.A.R.E/index.cfm.

4. Reaves, J. (2001). Time, U.S. Just say no to DARE. Accessed on December 1, 2011 at: http://www.time.com/time/nation/article/0,8599,99564,00.html#ixzz1fFIMYosm.

5. Lynam DR et al. Project D.A.R.E.: No Effect at 10 Year Follow up. Journal of Consulting and Clinical Psychology 1999; 67: 590-593.

6. University of Twente. Health Communication. Theory of Planned Behavior/Reasoned Action. Accessed on December 1, 2011 at: http://www.utwente.nl/cw/theorieenoverzicht/Theory%20clusters/Health%20Communication/theory_planned_behavior.doc/.

7. Siegel, Lecture, Theory of Reasoned Action. Boston University School of Public Health. October 6,2011.

8. University of Twente. Health Communication. Health Belief Model. Accessed on December 2, 2011 at: http://www.utwente.nl/cw/theorieenoverzicht/Theory%20clusters/Health%20Communication/Health_Belief_Model.doc/.

9. Psychlopedia, Everything Psychology. Psychological Reactance Theory. Accessed on December 1, 2011 at: http://www.psych-it.com.au/Psychlopedia/article.asp?id=65.

10. Above the Influence, website. Accessed on December 2, 2011 at: http://www.abovetheinfluence.com/.

11. United States Government Accountability Office (2006). ONDCP media campaign: contractor’s national evaluation did not find that the youth anti-drug media campaign was effective in reducing youth drug use.

12. Frontline. Inside the Teenage Brain. Accessed on December 1, 2011 at: http://www.pbs.org/wgbh/pages/frontline/shows/teenbrain/interviews/todd.html.

13. Common Sense, for Drug Policy. The Effective Drug Control Strategy 1999. Accessed on December 2, 2011 at: http://www.csdp.org/edcs/page10.htm.

14. Bradley, I. (2011). Clinical Correlations. Ethical Considerations on the Use of Fear in Public Health Campaigns. Accessed on December 2, 2011 at: http://www.clinicalcorrelations.org/?p=4998.

15. National Cancer Institute. Optimistic Bias. Accessed on December 1, 2011 at: http://cancercontrol.cancer.gov/brp/constructs/optimistic_bias/index.html.

16. Truth Campaign. Protect the Truth. Accessed on December 2, 2011 at: http://www.protectthetruth.org/truthcampaign.htm.

17. Evans, W.D. Hastings, G. (2008). Chapter 1: public health branding: recognition, promise, and delivery of healthy lifestyles. Public Health Branding: Applying Marketing for Social Change, Oxford: Oxford University Press. 3-24.

18. Stone, D. (1993) Social Cognitive Theory. Learning. Accessed on December 1, 2011 at http://www.mendeley.com/research/social-cognitive-theory/#.

19. Luszczynska, A., Schwarze, R. Predicting Health Behavior. Social Cognitive Theory. Accessed on December 2, 2011 at http://www.ihepsa.com/files/predicting%20Health%20beh%20avior.pdf#page=144.

20. The 84, website. Accessed on December 2, 2011 at: http://the84.org/.

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.

References

1. Center for Disease Control (CDC). Overweight and Obesity Basics. Atlanta, Georgia: Center for Disease Control. April 2011. Available at: http://www.cdc.gov/obesity/childhood/basics.html. Accessed December 14, 2011.

2. CDC. Obesity Data and Statistics. Atlanta, Georgia: Center for Disease Control. April 2011. Available at: http://www.cdc.gov/obesity/childhood/data.html. Accessed December 14, 2011.

3. FatSmack.org. Boston, Massachusetts: Boston Public Health Commission. 2011. Available at: http://fatsmack.org/. Accessed December 15, 2011.

4. Boston Public Schools. Boston Public Schools at a Glance. Boston, Massachusetts: BPS Communications Office. April 28, 2011. Available at: http://www.bostonpublicschools.org/facts-and-figures. Accessed December 14, 2011.

5. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001 Feb 17;357(9255):505-8.

6. Campbell, PhD. M., Benton J, Werk L. 5-2-1-Almost None: Parents' Perceptions of Changing Health-Related Behaviors in Their Obese Child. The Permanente Journal. 2009 Summer; 13(3): 4–8. Available at: http://www.ncbi.nlm.nih.gov.ezproxy.bu.edu/pmc/articles/PMC2911809/?tool=pubmed.

7. Goldberg, C. ‘Don’t Get Fat-Smacked!’ Boston Blitz Targets Sugary Drinks. Boston, Massachusetts: WBUR. September 6, 2011. Available at: http://commonhealth.wbur.org/2011/09/boston-sugary-drink/. Accessed December 14, 2011.

8. sugar smarts. Boston, Massachusetts: Boston Public Health Commission. 2011. Available at: http://www.sugarsmarts.com/pages/home.aspx. Accessed December 15, 2011.

9. City of Boston. Mayor Menino Issues Order to End Sugary Drink Sales on City Property. Boston, Massachusettes: City of Boston. 2011. Available at: http://www.cityofboston.gov/news/default.aspx?id=5051. Accessed December 15, 2011.

10. Prinstein M, Boergers J, Spirito A. Adolescents’ and Their Friends’ Health-Risk Behavior: Factors That Alter or Add to Peer Influence. Journal of Pediatric Psychology. 2001; 26:287-98.

11. Thaler RH, Sunstein CR. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008, pp. 53-71.

12. Boston Magazine. The City’s New Anti-Sugary Beverage Campaign is Kind of Gross. Boston, Massachusettes: Daily Feed. September 17, 2011. Available at: http://blogs.bostonmagazine.com/boston_daily/2011/09/07/sept-11-boston-mayor-menino/. Accessed December 15, 2011.

13. Nam-Krane, D. Don’t Get Smacked by Boston’s Fat Smack Campaign. Boston, Massachusetts: South End Patch. November 27, 2011. Available at: http://southend.patch.com/blog_posts/dont-get-smacked-by-bostons-fat-smack-campaign. Accessed December 15, 2011.

14. Miller, M. Boston Beans Sugary Drinks with New Public Health Push. Boston, Massachusetts: Brand Channel. September 13, 2011. Available at: http://brandchannel.com/home/post/2011/09/13/Boston-Sugary-Drinks-Campaign.aspx. Accessed December 15, 2011.

15. Schulze M, Manson J, Ludwig D, Colditz G, Stampfer M, Willett W, et al. Sugar-Sweetened Beverages, Weight Gain, and Incidence of Type 2 Diabetes in Young and Middle-Aged Women. JAMA. 2004:292(8):927-934. Available at: http://jama.amaassn.org.ezproxy.bu.edu/content/292/8/927.long.

16. Witte, K and Allen M. A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns. Health Education and Behavior 2000;27(5):591-615.

17. Professor Siegel, M. Class Lecture. Alternative Models of Behavior Change: Introduction. Boston University. 20 Oct 2011.

18. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH) Publication No. 05-3896.

19. Fat Smack.org. 2011. Available at: http://www.facebook.com/pages/FatSmackorg/229446067100670?sk=wall. Accessed December 15, 2011.

20. City of Boston. Boston wins 4^th census challenge; city’s population continues to grow. Boston, Massachusetts: City of Boston. 2011. Available at: http://www.cityofboston.gov/news/default.aspx?id=4449. Accessed December 15, 2011.

21. Professor Siegel, M. Class Lecture. Stigma Theory and Labeling Theory. Boston University. December 8, 2011.

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: http://www.regionalindicators.org/equity/economy/poverty-rate/. Accessed December 15, 2011.

25. Lenzer J. New York City push against sugary drinks sparks controversy. BMJ 2010;341:c5763.

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.

29. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarettes use and intentions following implementation of a tobacco control program: Findings for the Florida Youth Tobacco Survey, 1998 – 2000. JAMA 2000; 284: 723 – 728.

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.