Do Anti-Smoking Ads Lead To Avoidance Of Smoking Or Avoidance Of The Ads? – Neha Jha

The Impact of Tobacco on Society:

Tobacco has a huge global disease burden with significant detrimental effects on health related quality of life. According to the Center for Disease Control & Prevention, “20.6% of all adults or 46.6 million people were current smokers in the year 2009” (1). In the United States, “tobacco use causes one in five deaths annually or about 443,000 deaths per year, and an estimated 49,000 of these tobacco-related deaths are the result of secondhand smoke exposure” (1). Smoking causes cancer, heart disease, stroke, and lung diseases such as emphysema, bronchitis, and chronic airway obstruction (1). Smoking is estimated to cost $193 billion in lost productivity and health care expenditures (1). It is the bane of society since it drains valuable dollars that could be spent in other health care costs.

As of 2008, “Smoking prevalence in the United States has dropped by half since the first Surgeon General’s Report on Smoking and Health was published in 1964, but tobacco use still causes over 400,000 premature deaths each year” (2). The World Health Organization estimates that the smoking epidemic could claim one billion lives by the end of this century, worldwide (2).

What We Are Doing About It:

Millions of dollars have been spent on anti-smoking advertising and millions will continue to be spent over the years to reduce the number of people affected by the often deadly consequences of smoking. The New York City (NYC) Department of Health is the sponsor of several anti-smoking ads as part of their larger “NYC Quits” anti-tobacco campaign. The content of these ads are meant to inform people of the serious health consequences of smoking and encourage them to attend the free nicotine replacement patches and gum giveaway events held regularly. But their approach in designing the televised ads is questionable. Even as a non-smoker viewing these ads, one wonders how to avoid the uncomfortable feeling evoked by watching the ad.

Why Advertising Might Be A Great Tool:

Statistics from 2006 reveal that up to 30% of individuals who recently quit smoking attributed their attempt to quit due to anti-tobacco advertising (3). In fact, anti-smoking advertisements were found to be the single most effective smoking cessation aid (3). There are several reasons why mass media and television advertisements are appropriate tools to tackle the huge task of curbing smoking and reduce it to the lowest achievable proportions. Televised advertisements combine both visual and auditory cues that provide a multisensory experience. These ads are watched by millions of people giving us a direct mode to reach large numbers of people with a simple yet sensitively and effectively created message. There is research to show that media portrayal of events has a large impact of the expectations of society (4). There is also research indicating that anti-smoking counter-advertising impacts youth’s tobacco related beliefs (3).

Unfortunately, much of the research on anti-smoking advertising and its influence is based on feedback from younger, college-going students who are not representative of the entire population of smokers. The 2003 article by Agostinelli, mentions that the research up until now has focused disproportionately on non-smokers compared to smokers (5). Most anti-tobacco counter-advertising research focused on the efficacy of preventing smoking initiation among young nonsmokers, with less attention given to studying smokers. We must interpret the results of these studies with non-smokers carefully because “…anti-smoking communications can backfire and strengthen initial pro-smoking attitudes when viewed by smokers” (5).

Many of the recommendations on principles to follow in anti-tobacco advertising are based on observations and data obtained through interviews with focus groups. Consequently, investigators could only obtain self-reported attitudes and not real behavior. Another reason to be cautious in using the principles following from this research is that predisposition has an effect on how anti-smoking messages are received, processed and viewed (6). And so the same messages that evoke a reaction and long term health behavior change in some will be insufficient or inappropriate to initiate a behavior change in others.

Components of the Ads That Do Not Work:

It is important for smokers to be informed about the reality of the adverse consequences of tobacco on their health and quality of life. Smoking impacts both the smoker directly by leading to or speeding up the process of development of heart disease, cancer, COPD, emphysema, bronchitis, etc. A smoker’s health deterioration also affects their partner, children, parents and friends who care about them and depend on them. Additionally, people around them risk facing adverse health effects due to second hand smoke. Smokers should be encouraged to realize that their decision to smoke affects the quality of their life while also impinging on the emotional and physical well being of people who they care for and who care for them.

We need to use advertisements as a mode in which we incorporate those principles that are most likely to produce a lasting change in a viewer’s smoking behavior. The NYC Quits anti-smoking advertising tries to do just that. But some elements of their ads indicate a subtle oversight of what might be more effective; other elements are downright disturbing.

An example is the “Reverse The Damage” Ad that states, “20 minutes after you quit smoking, your blood pressure decreases. After 2 days, your chance of heart attack drops. And 1 year after you quit, your risk of heart disease drops in half, but right now…” (7). This is when the visuals include gory images of open chests with diseased, live and beating hearts, chilling images of sharp surgical tools inside bloody chests gushing blood and the use of defibrillators are depicted. The voice behind the ad continues, “…but right now, you’re a heart attack waiting to happen. Every cigarette makes you sick. More than 1 million Americans are living with the misery of a stroke caused by smoking” (7). This is just one advertisement out of dozens sponsored by NYC’s Department of Health that has the potential to shock and upset a viewer.

The questionable elements are the framing of the advertisement to be gain or loss framed (i.e. indicating health benefits to be gained or quality of life to be lost), the use of fear through graphic images or videos and the use of statistics instead of personal narratives to initiate health seeking behavior in smokers. This paper systematically evaluates these three elements and seeks to offer alternative ways to reach the goal of decreasing the prevalence of smoking in the population.

I. Message Framing In The NYC QUITS Ads:

The NYC Quits campaign involves television advertisements that frame the health promoting message in a negative manner. Comments such as, “Dying from smoking is rarely quick…and never painless” or “When smoking leads to stroke, you can suffer every minute of everyday” or phrases that sound something like, “If you smoke, you are a stroke waiting to happen or one cigarette closer to cancer” are all examples of negative framing of the consequences of smoking (8,9).

In the context of what influences smokers to take positive action to quit smoking, the delivery of messages in a “gain frame” as opposed to a “loss frame” is of great interest. “Health communications can be framed in terms of the benefits of engaging in a particular behavior (a gain frame), or in terms of the costs of failing to engage in the behavior (a loss frame)” (10). Framing of messages can be thought of as providing a context in which to evaluate a problem. “The way in which a message is framed affects the amount of persuasion it elicits” (11).

Most smokers are aware of the negative outcomes but they continue the addictive behavior. Some young smokers might be more likely to continue smoking because it shows a sense of rebellion, independence and risk taking which they may feel makes them more attractive to others and therefore popular among them (12). They may also be overly optimistic about judging their risk for the negative consequences and feel that they will not be affected by the outcomes. According to Witte, people may feel that the risk is not significant or relevant (13). So negative framing might actually have very little impact to those people who are risk takers or those who feel that they will not be the ones to get sick.

Relative to younger people, older people reported positive messages more informative than negative ones and tended to have a better memory for positive messages (14). So for both young and older adults, we see benefits of using positive framing.

An interesting theory that can be used as a framework to understand the effect of framing on smoking behavior is the Prospect Theory. This theory was developed by Kahneman and Tversky who postulated that “people underweight outcomes that are merely probable in comparison with outcomes that are obtained with certainty” (15). The theory suggests that choices with relatively certain outcomes are more likely to be considered when people are faced with the potential positive consequences that might follow, but risky choices with uncertain outcomes are motivated when people focus on potential negative consequences.

Utilizing this model to understand the appropriateness of negative and positive frames in different contexts, since behaviors such as smoking avoidance or cessation are associated with certain outcomes such as better health and reduced illness risk, a gain-framed outcome is a better approach. “Although most messages about tobacco use are loss framed in that they focus on the costs associated with smoking, a potentially more effective approach might be to emphasize the benefits or gains that can result from smoking avoidance and cessation” (16). Schneider et. al also reported that “in general then, gain-framed messages led to greater acceptance of the idea that there are benefits of avoiding smoking and to viewing different temptations as less likely to lead to smoking” (16). The Prospect Theory along with the research by Schneider indicates that using a gain frame for anti-smoking ads will have a better outcome. “…for smokers, any type of gain frame, visual or auditory, decreased temptations to smoke when stressed” (16).

A gain frame perspective such as that put forth by phrases such as “Reverse the damage - 20 minutes after you quit smoking, your blood pressure decreases. After 2 days, your chance of heart attack drops. And 1 year after you quit, your risk of heart disease drops to half of that of a non-smoker” are helpful in showing viewers the positive effects that quitting cigarettes could have on their health (7). But such an approach should be used independently instead of in combination with negative framing and threatening images such as those used in the NYC Quits Ads.

By focusing on the positive outcomes smokers can look forward to after they quit, we give them the incentive to work towards a positive outcome rather than avoid a negative outcome. In this context, the concept of “self-efficacy” is a theoretical construct postulated by Bandura in 1977. He suggested the idea of self-efficacy as a cognitive mechanism that supports behavioral change. Bandura stated that “expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences” (17). The gain frame messages should incorporate positive messages that increase self-efficacy of the viewer making them more confident in their ability to achieve the challenging task of quitting smoking and maintaining the behavior over their lifetime.

II. Use of Fear Appeals and Threatening Themes:

An endoscope being thrust down someone’s trachea and lungs to show a tumor in the lung completely blocking the airway and the person gasping for breath with a actor dressed like a doctor saying, “By the time most lung cancers are found, it’s already too late”; depicting newborns, infants and toddlers attached to naso-gastric tubes and respirators with accompanying narrative that states “Cigarettes are eating you and your kids alive”; explicit and graphic images of diseased lungs, hearts and oral cavities, surgeries in progress, surgical tools covered in blood, etc - are all scenes meant to inspire fear (18).

These ads incorporate elements of fear and shock to spur the audience to take action. They are known as “fear appeals”. “Fear appeals are persuasive messages that are designed to scare people by describing the terrible things that will happen to them if they do not do what the message recommends” (13). Fear appeals contain explicit or gruesome content such as vivid language, personalized language, or gory images. The fact that they grab the audiences’ attention initially is quite obvious. The disturbing images or stories are hard to ignore. But are they having the desired effect?

Health promotion messages with threatening themes are meant to make viewers perceive a threat. “Perceived severity is an individual’s belief about the seriousness of a threat” and “perceived susceptibility is an individual’s beliefs about his or her chances of experiencing the threat” (13). These components of perceived threat - perceived severity and perceived susceptibility relate directly to two factors outlined in the Health Belief Model.

This current Health Belief Model states that a person’s health seeking behavior and other health behavior is motivated by six factors: a) perceived severity, b) perceived susceptibility, c) perceived benefits of an action, d) perceived barriers to taking that action, e) cues to action and f) self-efficacy (19). The Health Belief Model falls short in many respects such as ignoring the influence of social and environmental factors such as community and cultural factors, not differentiating between attitudes and their translation into behaviors and assuming that providing information will change behavior.

The Health Belief Model alone is an incomplete model to utilize in a public service announcement. Moreover, the fear appeals approach, through the use of disturbing themes underutilizes the model. It reminds the viewer about perceived severity and susceptibility through intimidating images. By throwing in some facts about positive health outcomes along with powerful and intimidating images that inspire fear, it downplays the perceived benefits of an action and neglects to increase the self-efficacy of individuals. So the smoker watching the ad is not encouraged or made to feel capable of taking the recommended action to succeed in implementing and maintaining it.

Tobacco ads that show disturbing images of diseased lungs are meant to have a dramatic and powerful impact on smokers so that they inspire immediate action. But these grotesque images have been shown to trigger a defensive reaction in smokers which causes them to stop processing the images and tune them out. So “…the smoker avoids the disturbing images rather than avoid smoking” (20).

The Psychological Research on Information and Media Effects Lab claims that health promotion messages that included threatening or graphic images resulted in “greater attention, better memory and a heightened emotional response” (20). There is no doubt that fear is accompanied by anxiety and a high level of physiological arousal (13). But other research suggests that smokers who showed a defensive response and stopped processing the threatening images exhibited lower memories and emotions response towards the images. A study by Hammond et al. (21) finds that “1% of smokers reported smoking more when seeing threatening visual warnings: 36% reported making some efforts to avoid the labels and 13% felt that the warnings were not credible” (21). Since people deal with fear by denying that there is an impending threat and risk of illness, they avoid the threat thereby leading to message rejection.

The defensive reaction phenomenon can be supported by the Extended Parallel Process Model. The model was proposed by Kim Witte, who suggested that when perceived efficacy or self-efficacy is less than a perceived threat, people feel that they are unable to escape the threat (13). They look for a way to decrease the level of anxiety and reduce the emotion of fear through “defensive avoidance”. As we might imagine, such images and the resulting defensive reactions lower the level of message acceptance therefore cannot be used to change attitudes and behaviors especially in a long term process such a quitting smoking.

The Protection Motivation Model developed by R.W. Rogers in 1975 is another model to address the fear control process. It suggests that fear appeals must be combined with messages that focus on efficacy of the recommended intervention, in our case, smoking cessation (22). According to Witte, who builds upon the Protection Motivation Model, fear appeals must be supplemented with messages that increase self-efficacy of the individual (13). This will increase the chances that the recommended intervention will be adopted and maintained. But according to the article by Gallopel-Morvan, the right combination of self-efficacy and fear appeals has not been researched enough (23). The alternative might be to rely on positive framed advertisements and supplement them with messages that increase self-efficacy. In order to make anti-smoking ads more effective, visual or auditory cues that increase self-efficacy should be incorporated. Messages that promote higher self-efficacy would sound like “You are able to easily and effectively lower your chances of chronic lung diseases and certain cancers if you quit smoking”. Besides support from the model, it seems even instinctively that given a choice between visualizing gasping for air due to emphysema and imagining a dazzling, white smile, a viewer would choose to think about the nicer picture.

III.Using Statistics To Call Attention To The Devastating Effects Of Smoking On Health:

In their dramatic anti-tobacco advertisements, the NYC Quits program provides statistics of how many people are affected by smoking related diseases every year. It assumes that the viewer is not aware of the magnitude of problems that smoking can cause. It also assumes that knowing about the numbers will increase a smoker’s perception of perceived risk. But statistics don’t do much other than prolong the length of an ad. Examples from the NYC Quits campaign are: “4 million Americans live with the misery of emphysema caused by smoking” or “More than 1 million Americans are living with the misery of a stroke caused by smoking” (8,24). Facts alone are not relatable and do not draw the viewer in.

A powerful tool for reaching people and touching their hearts when it comes to promoting change of a certain behavior in them is personal narratives. In their article, Meisel & Karlawish state that narratives have been shown to improve individual health behaviors in multiple settings (25). Although the scientific and public health community considers statistical evidence the most reliable evidence, using facts and figures to translate data and bring attention to the multiple health effects of smoking and the multitudes of people affected may not be effective. Meisel & Karlawish state that stories are an essential part of how individuals understand and use evidence (25). Collecting concrete evidence is the first step to understanding the negative outcomes of addictive behaviors such as smoking but providing smokers this information as a tool to convince them underestimates the complexity of the problem and the grip that the addictive behavior has on them. “…Evidence from social psychology research suggests that narratives, when compared with reporting statistical evidence alone, can have uniquely persuasive effects in overcoming preconceived beliefs and cognitive biases” (25). Messages that primarily use statistics to inform people assume that if we give people the information, they will be rational and will use it to change their current behavior and adopt a new one. This is another example of the idea presented in the Health Belief Model which does not differentiate between attitudes and actual behavior.

Why are public service announcements or advertisements that use a narrative approach more successful in their goal? To address this question, Dunlop et. al explain the role of an intrapersonal process in the level of engagement in a health message. They suggest that the extent to which an individual becomes involved with the narrative depends on a phenomenon known as transportation (26).

The Transportation Theory was developed by Melanie Green and Timothy Brock during their research on public narratives to which numerous people are exposed to during different occasions or at the same time. They describe transportation into a narrative world as “as a distinct mental process, an integrative melding of attention, imagery, and feelings” (27). It is accompanied by a psychological distancing from reality. Green and Brock explain that the major elements of the transportation experience are cognitive attention to the narrative, emotional involvement, lack of awareness of the surroundings, and formation of mental imagery (27).

Transportation leads to three consequences that are important in how we design and implement anti-tobacco advertisements. “The first consequence is that parts of the world of origin become inaccessible” (27). The reader, viewer or listener loses touch with real-world facts while accepting the narrative world and in fact “may be less aware of real-world facts that contradict assertions made in the narrative” (27). Another consequence is that transported viewers may experience strong emotions and motivation in spite of the knowledge that the events in the story may not be real. Thirdly, people return from being transported changed by the experience. These consequences are predicted to occur regardless of whether the narrative is based on true events. This implies that the phenomenon of transportation through narratives may be an important method to produce anti-smoking messages that the audience will take to heart.

Smoking is a problem that requires a long term solution, not just an initial “cue for action”. As public health experts, we must evaluate what types of ads are most believable and relatable to the viewer thereby providing the most appropriate cue for change and increasing the chances of creating a lasting impression. “…narratives have been shown to be most helpful for boosting clarity and believability of a health message if recipients identify with characters from the stories” (25). In this article, the authors relate evidence that suggests that those who provide only evidence without narratives about real people are unable to have the desired impact.

A Look at the Future of Anti-Tobacco Advertising: Advertising is a large field in itself but advertising of health related messages is a specialized field that requires in-depth understanding not only about the principles of advertising but also how public health messages are received and processed. Although over the decades, anti-tobacco counter advertising has become more sophisticated in its approach, several deficiencies in understanding the principles of social and behavioral psychology are undermining their effectiveness. Fear tactics and negative framing, while they do initially catch the viewer’s attention do not produce any significant long term change and in fact evoke defensive avoidance. No human being wants to be bullied by the government, public health officials, health care providers or anyone else for that matter. By giving smokers a positive picture to look forward to and work towards, and increasing their self-efficacy, we give them a better set of tools to work with. Narratives that people can relate to make creative messages that are easily accepted and can move people to take action. It is in the best interest of researchers, public health officials and citizens and tax payers to maximize the influence of the advertisements while reaching the greatest number of people. We should aim to target these appropriate elements in an individual’s psyche that produce the greatest change in their addictive behavior.

REFERENCES:

1. CDC - Fact Sheet - Fast Facts - Smoking & Tobacco Use. (2011, March).Center for Disease Control & Prevention. Retrieved December 14, 2011, from http://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/#cost

2. Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health behavior and health education: Theory, Research And Practice. Retrieved from http://books.google.com.ezproxy.bu.edu/books?hl=en&lr=&id=WsHxyj710UgC&oi=fnd&pg=PR5&dq=HEALTH+BEHAVIOR+AND+HEALTH+EDUCATION&ots=EVOZYeLl-M&sig=rq3nn5_iJHSkXso1oAaqi7KCHbk#v=onepage&q=HEALTH%20BEHAVIOR%20AND%20HEALTH%20EDUCATION&f=false

3. Biener, L., Reimer, R. L., Wakefield, M., Szczypka, G., Rigotti, N. A., & Connolly, G. (2006). Impact of smoking cessation aids and mass media among recent quitters. American Journal of Preventive Medicine, 30(3), 217–224.

4. Berkowitz, L. (1984). Some Effects of Thoughts on Anti- and Prosocial Influences of Media Events: A Cognitive-Neoassociation Analysis. Psychological Bulletin, 95(3), 410-427.

5. Agostinelli, G., & Grube, J. W. (2003). Tobacco Counter-Advertising: A Review of the Literature and a Conceptual Model for Understanding Effects. Journal of Health Communication, 8(2), 107-127. doi:10.1080/10810730305689

6. Wakefield, M., Flay, B., Nichter, M., & Giovino, G. (2003). Role of the Media in Influencing Trajectories of Youth Smoking. Addiction, 98(s1), 79-103.

7. NYC Department of Health - NYC Quits (2010). Reverse the Damage. Video retrieved from http://www.youtube.com/watch?v=Tyqh5x0AmSg on December 13^th, 2011

8. NYC Department of Health - NYC Quits (2010). Suffering from Stroke. Video retrieved from http://www.youtube.com/watch?v=h6vwNbx_afY on December 13^th, 2011

9. NYC Department of Health - NYC Quits (2010). Lung Cancer. Video retrieved from http://www.youtube.com/watch?v=Z5wY56SrtvY on December 13^th, 2011

10. Sherman, D. K., Mann, T., & Updegraff, J. A. (2006). Approach/avoidance motivation, message framing, and health behavior: understanding the congruency effect. Motivation and Emotion, 30(2), 164-168. doi:10.1007/s11031-006-9001-5

11. Smith, S. M., & Petty, R. E. (1996). Message Framing and Persuasion: A Message Processing Analysis. Personality and Social Psychology Bulletin, 22, 257-268.

12. Amos, A., Gray, D., Currie, C., & Elton, R. (1997). Healthy or druggy? Self-image, ideal image and smoking behaviour among young people. Social Science & Medicine, 45(6), 847–858.

13. Witte, K. (2009). Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs, 59(4), 329-349.

14. Shamaskin, A. M., Mikels, J. A., & Reed, A. E. (2010). Getting the message across: Age differences in the positive and negative framing of health care messages. Psychology and Aging, 25(3), 746-751.

15. Kahneman, D., & Tversky, A. (1979). Prospect Theory: An Analysis of Decision Under Risk. Econometrica, 47(2), 263-292.

16. Schneider, T. R., Salovey, P., Pallonen, U., Mundorf, N., Smith, N. F., & Steward, W. T. (2006). Visual and Auditory Message Framing Effects on Tobacco Smoking. Journal of Applied Social Psychology, 31(4). Retrieved from http://onlinelibrary.wiley.com.ezproxy.bu.edu/doi/10.1111/j.1559-1816.2001.tb01407.x/pdf

17. Bandura, A. (1977). Self-efficacy: Toward a Unifying Theory of Behavioral Change. Psychological Review, 84(2), 191-215.

18. NYC Department of Health - NYC Quits (2010). Cigarettes are eating you and your kids alive. Video retrieved from http://www.youtube.com/watch?v=Z5wY56SrtvY on December 13^th, 2011

19. Edberg, M. (2007). Individual Health Behavior Theories. Essentials of Helath Behavior: Social and Behavioral Theory in Public Health (pp. 129-132).

20. IB Times Staff Reporter. (2011, August 24). Usefulness of Grim Anti-Smoking Warnings Doubted. International Business Times. News, . Retrieved December 13, 2011, from http://www.ibtimes.com/articles/202900/20110824/study-doubts-fda-s-anti-smoking-campaign.htm

21. Hammond, D., Fong, G. T., McDonald, P. W., Brown, K. S., & Cameron, R. (2004). Graphic Canadian cigarette warning labels and adverse outcomes: Evidence from Canadian smokers. American Journal of Public Health, 94(8), 1442.

22. Rogers, R. W. (1975). A Protection Motivation Theory of Fear Appeals and Attituge Change. The Journal of Psychology, 91, 93-114.

23. Gallopel-Morvan, K., Gabriel, P., Le Gall-Ely, M., Rieunier, S., & Urien, B. (2011). The use of visual warnings in social marketing: The case of tobacco. Journal of Business Research, 64(1), 7–11.

24. NYC Department of Health - NYC Quits (2010). Emphysema. Video retrieved from http://www.youtube.com/watch?v=qzpPN67V-Ag on December 13^th, 2011

25. Meisel, Z. F., & Karlawish, J. (2011). Narrative vs Evidence-Based Medicine—And, Not Or. JAMA: the journal of the American Medical Association, 306(18), 2022–2023.

26. Dunlop, S. M., Wakefield, M., & Kashima, Y. (2008). The Contribution of Antismoking Advertising to Quitting: Intra- and Interpersonal Processes. Journal of Health Communication, 13(3), 250-266. doi:10.1080/10810730801985301

27. Green, M.C., Brock, T.C. (2000). The Role of Transportation in the Persuasiveness of Public Narratives. Journal of Personality and Social Psychology, 79(5), 701-721.

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.

REFERENCES

1.) Substance Abuse and Mental Health Services Administration. 2011. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Available at: http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm#2.2. [Accessed: 10 Dec 2011].

2.) National Institute on Drug Abuse. Aug 2010. NIDA InfoFacts: High School and Youth Trends. Available at : http://www.nida.nih.gov/infofacts/hsyouthtrends.html. [Accessed: 11 Dec 2011].

3.) Levine, DA. 2007. “Pharming:” The Abuse of Prescription and Over-the-Counter Drugs in Teens. Current Opinion in Pediatrics. 19(3): 270-274.

4.) Johnston, L.D., O’Malley, P.M., Bachmam, J.G., and Schulenberg, J.E. 2011. Monitoring the Future National Results on Adolescent Drug Use: Overview of Key Findings, 2010. Ann Arbor: Institute for Social Research, the University of Michigan.

5.) Office of National Drug Control Policy. 2011. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. 2011 Prescription Drug Abuse Prevention Plan. Available at: http://www.whitehouse.gov/ondcp/prescription-drug-abuse. [Accessed: 10 Dec 2011].

6.) The National Youth Anti-Drug Media Campaign. 2011. Parents, The Anti-Drug. Available at: http://www.theantidrug.com/. [Accessed: 10 Dec 2011].

7.) The National Youth Anti-Drug Media Campaign. 2011. Above the Influence. Available at: http://www.abovetheinfluence.com/facts/drugspresciptionrx. [Accessed: 10 Dec 2011].

8.) Dunleavy, B. Nov 2011. Anti-Drug Campaigns May Be Ineffective for Teens. Anesthesiology News. 37(11). Available at: http://www.anesthesiologynews.com/ViewArticle.aspx?d=Pain+Medicine&d_id=2&i=November+2011&i_id=785&a_id=19653. [Accessed: 11 Dec 2011].

9.) Andrews, K., Silk, K., and Eneli, I. 2010. Parents as Health Promoters: A Theory of Planned Behavior Perspective on the Prevention of Childhood Obesity. Journal of Health Communication. 15(1): 95-107.

10.) Judson, R and Langdon, S. 2009. Illicit Use of Prescription Stimulants Among College Students: Prescription Status, Motives, Theory of Planned Behavior, Knowledge and Self-Diagnostic Tendencies. Psychology, Health and Medicine. 14(1): 97-104.

11.)Molmberg, M., Overbeek, G., Vermulst, A., Monshouwer, K., Vollebergh, W., Engles, R. 2011. The Theory of Planned Behavior: Precursors of Marijuana Use in Early Adolescence. Drug and Alcohol Dependence. (Epub ahead of print). Available at: http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S0376871611004479. [Accessed: 11 Dec 2011].

12.) Edberg, M. Individual Health Behavior Theories. (pp. 40-42). In: Edberg, M. ed 2. Essentials of Health Behavior. Sudbury, MA. Jones and Bartlett Publishers. 2007.

13.) Cotto, J.H., Davis, E., Dowling, GJ, Elacanco, J.C., Staton, A.B., Weiss, S.R. 2010. Gender Effects on Drug Use, Abuse, and Dependence: A Special Analysis of Results from the National Survey on Drug Use and Health. Gender Medicine. 7(5): 402-413.

14.) Harrell, Z. and Broman, C. 2009. Racial/Ethnic Differences in Correlates of Prescription Drug Misuse Among Young Adults. Drug and Alcohol Dependence. 104(3): 268-271.

15.) Grier, S. and Bryant, C. 2004. Social Marketing in Public Health. Annual Review of Public Health. 26: 319-339.

16.) Randolph, W., and Wiswaneth, K. 2004. Lessons Learned from Public Health Mass Media Campaigns: Marketing Health in a Crowded Media World. Annual Review of Public Health. 25: 419-437.

17.) Hong, S., Giannakopoulos, E., Laing, D., Williams, N. 1994. Psychological Reactance: Effects of Age and Gender. Journal of Social Psychology. 134(2): 223-228.

18.) Hong, S. 1992. Hong’s Psychological Reactance Scale: A Further Factor Analytic Validation. Psychological Reports. 70: 512-514.

19.) Kreuter, M. and Strecher, V. 1995. Changing Inaccurate Perceptions of Health Risk: Results from a Randomized Trial. Health Psychology. 14(1): 56-63.

20.) Defleur, M. and Ball-Rokeach, S. Socialization and Theories of Indirect Influence (pp. 219-226). In: Defleur, M. and Ball-Rokeach, S, ed. 5. Theories of Mass Communication. White Plains, NY. Langmun Inc. 1989.