Why Graphic Health Warnings on Cigarette Packages Backfire: A Public Health Intervention That Will Increase Smoking –Rachel Yorlets Bryte

Introduction to Cigarette Use

Tobacco addiction has been identified by the Food and Drug Administration (FDA) as the predominant cause of early and preventable mortality in the United States. According to the Center for Disease Control and Prevention (CDC), cigarette smoking is responsible for 443,000, or 1 in 5 deaths annually in America. Of 312.8 million Americans (13), 44.6 million are cigarette smokers, and about 88 million nonsmokers are affected by secondhand smoke (2). Each year, the American economy suffers a loss of almost $200 million in healthcare costs and productivity loss caused by tobacco use (22).

Tobacco contains nicotine, an addictive drug that is absorbed into the bloodstream when smoke is inhaled. Nicotine stimulates adrenal glands, releasing epinephrine, which stimulates the central nervous system. This process elevates heart rate, blood pressure, glucose levels, and respiration rate. In addition, nicotine increases dopamine, which is the neurotransmitter associated with pleasure and satisfaction. Someone addicted to tobacco will experience a variety of withdrawal symptoms when they attempt to quit, including cravings, difficulty focusing and sleeping, and mood and appetite changes (15).

Cigarette smoking increases the risk of developing a number of health problems, affecting nearly every organ in the body. Cigarette smokers have an increased risk for cancers, including that of the lung, pharynx, esophagus, larynx, kidney, uterine cervix, urinary bladder, lip, pancreas, mouth and lip. Male and female smokers have 23 and 13 times the risk, respectively, of developing lung cancer in contrast to those who have never smoked. Smokers are 2 to 4 times more likely to have coronary heart disease, 10 times as likely to die from chronic obstructive lung disease, and 2times as likely to have a stroke (3). More than 80% of smokers develop the habit before age 18, and each day approximately 3,450 people under age 18 try a cigarette for the first time. Of these youth each day, about 850 become daily smokers. According to the CDC’s analysis of the 2010 National Health Interview Survey Data, about 70% of smokers want to quit, about 52% tried to quit during 2010, and of them, about 6% successfully quit during 2010 (4).

Introduction to Graphic Health Warnings on Cigarette Packages

In June of 2009, the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) was passed, requiring the development of 9 new, bigger warnings to be placed on cigarette packages and advertisements. This portion of the law was prompted by the research that showed the existing warnings were not very noticeable to customers. This idea was encouraged by the Institute of Medicine’s report in 2007that said that bigger warnings would communicate risks effectively, thereby prompting smokers to quit. International experiments have provided research supporting this theory. As a result, the FDA was directed by the Tobacco Control Act to use color graphic warnings that showed the health risks of smoking with the 9 text warnings. In addition, a resource must also be provided for a smoking cessation hotline (22).

In 2010, the FDA chose these 9 graphic images through a research study, consulting communications, graphic design, and marketing experts. Within the study, the FDA provided 36 tentative pictures to 18,000 subjects in a survey. The subjects were representative of 3 categories: adult smokers 25 years and older, young adult smokers aged 18 to 24, and youth aged 13 to 17 who were smokers or susceptible to starting to smoke. The FDA then determined the subjects’ ability to remember the pictures a few days after they viewed them (22). Researchers also considered the subjects’ emotional reaction to the pictures, but it did not, by any means seek to consider whether people would quit after seeing the images (18). As FDA spokesman, Jeffrey Ventura commented, the study only looked to agree with literature sources that graphic warning labels are effective, and that they are in line with the FDA’s interest in promoting education about smoking risks. “These warnings haven’t been updated since 1985, and anecdotal logic says that these warnings have become white noise,” justified Ventura. “The new generation of youth at risk are a very visually stimulated group of folks” (18).

The FDA posted its study results in December of 2010, and then considered them, along with literature resources, and public feedback on the study before selecting the final 9 graphic warnings. The FDA made this decision hoping that the new warnings would increase knowledge, promote smoking cessation, and discourage non-smokers from initiating smoking, and, by doing so, save lives, increase life expectancy, and reduce healthcare costs. The FDA even projected that, annually, they could prevent 16,544 to 19,687 people from smoking, and save 1,749 to 5,802 quality-adjusted life-years (22).

The graphic warning labels will be put into effect on September 22, 2011, after which no tobacco companies will be allowed to manufacture cigarettes without graphic warning labels (22). The new warning labels must occupy the left half of the front and the back surfaces of each cigarette package, replacing the existing Surgeon General’s warning. In addition, the FDA will continually monitor and evaluate the efficacy of the graphic warning labels, and consider the need for changes (22). However, an abundance of evidence already exists to demonstrate why these labels will not only fail to prevent smoking, but will serve to increase it. Public health professionals will then be forced to develop a new intervention that utilizes current research.

Critique I: Why the Health Belief Model Fails – Optimistic Smokers & Cognitive Dissonance

The Health Belief Model (HBM) is a social science theory that was used in the development of graphic warning labels for cigarette packages. The Health Belief Model postulates that there are three necessary criteria that must be fulfilled in order for someone to make a health-conscious decision. The first of these criteria is that there must be a health concern, or a sufficient source of motivation, in order for that particular health problem to matter to someone. Second, the person must believe that there is a “perceived threat”, meaning that they believe they are vulnerable to that health problem. Finally, one has to believe that making a particular, advised, health-related choice will result in a significant reduction of the perceived threat, and that this reduction will be beneficial. There is a condition on this final criterion: it must be satisfied at a “subjectively-acceptable cost.” In these terms, the cost describes the obstacles that must be surmounted by the individual for that person to make the advisable health-related choice. It must be noted that these obstacles may include financial problems (19).

In short, the HBM states that people will make the correct decision if they just have all the knowledge and ability necessary to do so (19). By placing the graphic health warnings on cigarette packages, the FDA assumes that people would quit smoking (and never start) if they just knew the dangerous health risks of smoking. However, social scientists know from extensive research that non-health-related factors play a substantial role in health behavior, including the choice to smoke. Specifically, smoking, as source of nicotine, is addictive, and involves psychological and physiological factors (8). Since HBM does not account for these elements, it is not an appropriate model for cigarette smoking.
The social science theory of cognitive dissonance further explains why HBM fails to prevent smoking. Cognitive dissonance results from an imbalance, or disequilibrium among one’s cognitions. This presence of “nonfitting relations” is essentially an “antecedent condition” that results in someone acting in a manner that will reduce that disequilibrium, or dissonance. Dissonance will not only prompt someone to reduce that imbalance, or clashing of different ideas, but it will also motivate that person to avoid and ignore any source of knowledge or any situation in which that clashing of ideas would be increased (7).

Cognitive dissonance occurs as smokers, who are well aware of the health risks of their behavior, continue to smoke for a number of reasons. First, the smoker thinks of the pleasure that smoking affords, and justifies smoking to achieve it. Second, the smoker does not really believe that he is vulnerable to the health risks of smoking, even though he may acknowledge that other people suffer from them. Third, the smoker continues to rationalize the act of smoking by thinking that he cannot possibly avoid every dangerous behavior in his life. Finally, the smoker rationalizes this exposure to a health risk by asserting that s/he would probably gain weight (another health problem) if s/he were to quit smoking (7).

Smokers will rationalize their decision to continue smoking when faced with graphic warning labels because of cognitive dissonance. “Consider this: a pack-a-day smoker will see these labels more than 7,000 times a year,” said Margaret A. Hamburg, the Commissioner of the FDA in a press statement (http://www.fda.gov/TobaccoProducts/Labeling/CigaretteWarningLabels/ucm259214.htm to view the statement) (23). Considering what is known about cognitive dissonance, one might readily agree that a pack-a-day smoker will see the labels more than 7,000 times yearly because that smoker will not have quit. Each time the smoker sees the label, or at least initially, the rationalizing arguments previously mentioned will enable that person to continue smoking. Beyond this, it seems unintelligent to attempt an intervention after the cigarettes are already being purchased, especially, since, after the new cigarette packages are in circulation, smokers will expect to see them, and still continue to buy them. Graphic warning labels seem to be, put simply, “too little, too late”. Carol Tavris, a behavioral psychologist interviewed by Science on this subject, even thinks that smokers that want to stop, but have not yet successfully, are especially likely to be unaffected by the new warnings. “Dissonance is a pretty powerful phenomenon,” says Tavris, that explains “why people continue to do things they know are harmful, but still see themselves as smart” (18).

Optimistic bias, another behavioral theory, explains why smokers continue to smoke after seeing these gruesome warnings. Optimistic bias is a simple concept: a person continues to believe that, while negative consequences may affect someone else, those consequences will not affect them personally. This optimistic bias is increased by an individual’s belief that they have control over their destiny (12). Essentially, the smoker believes that none of those health problems will happen to him/her.

Critique II: How Graphic Warnings Misuse Framing & Ignore Psychological Reactance Theory

Framing is the means by which a source depicts an issue of concern to the public. Framing is a powerful art that has the ability to affect change in the public’s opinion, and to convince people to see some health problems a certain way. This is critical because the public’s view of the problem, and consequently the problem’s causation, plays a considerable role in how they will respond to it (17).

Graphic health warning labels on cigarette packages frame smoking as a risky, dangerous behavior with serious, life-threatening consequences. Through negatively framing smoking, the labels are perceived as taking a freedom from smokers or people who are considering smoking. Instead, the same theory, while not denying the negativity of smoking, can choose to instead frame the issue in terms of liberating a smoker. For example, instead of reminding a smoker that tobacco kills, the label could remind people that quitting smoking restores a number of liberties, including financial ones. Telling a pack-a-day smoker about what he could purchase with the money he would save by not smoking may be more effective than threatening messages.

Psychological reactance, a social science theory, describes this phenomenon that explains why smokers will resist the graphic warning labels, perceiving them as a threat to their right to smoke. Psychological reactance postulates that when someone’s behavioral freedom is threatened, they will do what is in their power to prevent any further deprivation of liberty, and they will try to restore their freedom. When a person is told to not smoke through means of graphic warning labels, that person may perceive it as a threat to their freedom, and resist the label, while continuing to smoke as an attempt to regain or protect that threatened freedom. The amount of resistance and reactance expressed by an individual is directly related to the perceived importance of the freedom is threatened. This is why smokers will continue to smoke after they see the warnings, and why graphic warning labels will actually provoke those considering starting to smoke to do so as an assertion of their liberty (1).

Critique III: Scare Tactics Just Encourage Smoking

Terror management theory, an idea of social psychology, asserts that behavior mostly prompted and affected by the powerful human fear of death. The anthropologist Ernest Becker, made the argument that everything humans do is done in order to avoid and reject our own mortality. One might think that graphic health warnings would motivate smokers to quit for this reason, but in reality, it forces smokers to push aside that anxiety. According to the theory, self-esteem alleviates the stress caused by this reminder of mortality (21). Smokers may find some self-esteem, some belonging, and stress-relief in their smoking; this just reinforces their positive attitudes about tobacco. Several research studies show that warnings addressing mortality just encourage smokers to keep smoking (9).

Martin Lindstrom, author of Buyology, conducted a brain-imaging study in 2006, illustrating why graphic warning labels actually tend to encourage smokers to continue smoking. There were 32 subjects in the study, including residents of the United States, Japan, China, Germany, and Great Britain, some of whom were 2 pack-a-day smokers. The majority of them reported that graphic warning labels actually decreased their cigarette cravings, but Lindstrom’s research proved the exact opposite. Each subject was required to lay in a functional magnetic resonance imaging (fMRI) scanner for approximately 1 hour. During this time, the subject viewed a small screen, onto which several graphic warning labels were projected. These labels included textual warnings as well, indicating health risks of smoking. The scanning technique is able to detect oxygen and glucose levels within the brain, showing its activity. When each person saw the warning, there was no blood flow to the area of the brain that shows alarm and fear (the amygdale), or to the area of the cortex that indicates disapproval. Ironically, when subjects viewed the warnings, the nucleus accumbens, also known as the “craving spot” showed activity; this activity occurs when someone has a strong desire for drugs, tobacco, alcohol, or gambling (14). While more research is justified, it is surprising that the warning labels caused the subjects to want to smoke more. “We couldn’t help but conclude that these same cigarette warning labels intended to reduce smoking, curb cancer, and save lives had instead become a killer marketing tool for the tobacco industry,” said Lindstrom (14).

Another study, done at the University of Missouri by psychologist Jamie Arndt, supports the idea that reminding smokers of their mortality only increases their smoking. Arndt asked student smokers to fill out surveys that were designed to make them think of 1 of 2 situations: their mortality, or failing a test. After the questionnaire was completed, researchers offered cigarettes to students, and then analyzed the student’s smoking in terms of the length of time, flow, and volume of each puff they took. Those who were light smokers generally smoked with little intensity, but heavy smokers smoked with a lot of intensity after reading about their own mortality. Arndt explains this by saying that smokers use smoking (a source of pleasure) to deal with the negativity of thinking about death (20).
Proposed New Intervention: Using Labeling, Social Expectations, and Social Networking Theories to Utilize Social Networking Sites

Hundreds of millions of people around the world use social networking sites, such as Facebook, Twitter, and MySpace, but what are the implications of this network for public health professionals? Can these social networking sites be used for public health interventions, including smoking cessation? A new intervention might use labels for members of these sites, indicating that they are “Smoke-free since…” or “Trying to Quit”, or simply unstated. This part of information could be provided with equal simplicity as someone’s relationship status, place of employment, or education, is given. In addition, and most importantly, social networking sites can provide a forum for discussion, much like the Vapers Forum, which facilitates discussion of smoking alternatives (http://www.vapersforum.com/)(11). This would provide a supportive outlet through which smokers could discuss trying to quit, and those who recently quit could discuss improvements to their life and help each other stay smoke-free. Cessation resources could be provided through the forum, message board, or group. The forum would provide a form of accountability for those trying to quit, while the labels would give a constant reminder of pride to non-smokers, and additional motivation to those trying to quit.

Research suggests that, not only can complex relationship-based networks be utilized for a meaningful public health intervention, but that such an attempt would be likely to be effective. The network itself (which is made of many different groups) is all about relationships. The social network is usually composed of relationships among close friends, and family – people who have the power to influence an individual on important decisions like quitting smoking. Social networking theory, a group-level theory, says that social scientists can actually explain human behavior by looking at the social network, and not at the individual (5).

Social networking theory is particularly promising because there is an effect that occurs in the network, known as the “tipping point”. In other words, smoking cessation can flow within and throughout the networking site to a certain point (the tipping point), after which it will overflow, and everyone within the network will quit. This is also tied to the idea of what is referred to as “crowd behavior”, which is behavior change that is apparent to the entire network (5).

Why is this phenomenon so important to public health? Research shows that information is distributed throughout the social network, spreading a behavior (15). This phenomenon has been shown to be very applicable to promoting smoking cessation. “Smoking behavior spreads through close and distant social ties, groups of interconnected people stop smoking in concert, and smokers are increasingly marginalized socially,” says Nicholas Christakis, a researcher for the subject.
Once social networking is applied in a public health intervention for smoking cessation, it can be evaluated through network analysis, which describes graphically the relational nature of health behaviors (http://www.annualreviews.org.ezproxy.bu.edu/doi/full/10.1146/annurev.publhealth.28.021406.144132 to see how social networks are analyzed graphically) (15). Network analysis can describe the influence that social networks have on smoking cessation; this provides a method of evaluating the effectiveness of the intervention (15).
This proposed new intervention also takes advantages of social expectations theory, another group-level model, which is based on the fundamental social nature of humans. The theory postulates that everything in the human experience, from birth to death, is related to the social nature of humanity. Simply put, social expectations theory focuses on the behaviors or events that transpire between people, tying it closely to social networking theory. This theory describes how certain patterns within society define how individuals are expected to behave when they relate to those most important in their life. As being smoke-free becomes the norm, and smoking is marginalized, the social expectation changes, and essentially pressures smokers to quit (6).

Furthermore, research shows that labeling a person (as a nonsmoker, or one trying to quit would label them) actually institutes a type of self-fulfilling prophesy, in which the person will modify their behavior to meet their label (10). Once a person labeled as “trying to quit” is perceived by others, and treated by others, as such, and that person is reminded often of that label, that person eventually will fulfill it. Labeling would also have the impact of helping those who quit to remain smoke-free by their desire to fulfill the proud label of “nonsmoker”.

Conclusion

“Social psychologists have decades of research showing that fear communications generally backfire, that people tune them out, and therefore that these tactics are generally not effective,” says Tavris (20). In summary, although there are good intentions behind them, research strongly suggests that graphic health warnings will actually have the opposite effect, causing smokers to smoke more, and vulnerable non-smokers to consider starting to smoke. Instead, public health professionals would be wise to send positive messages about the benefits of being smoke-free, and to do so through the powerful social networking sites that millions of people use regularly. Through this intervention, the freedom of smoke-free can spread, marginalizing smokers, and providing positive outlets from which quitting smokers can gain support.

REFERENCES
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20. Schrock, Karen. How Smokers Think About Death: Do Graphic Warning Labels on Cigarette Packages Really Deter People from Lighting Up? Scientific American, 2010.

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22. U.S. Food and Drug Administration. Tobacco Products: Frequently Asked Questions: Final Rule “Required Warnings for Cigarette Packages and Advertisements”. Silver Spring, MD: U.S. FDA, 2011.

23. U.S. Food and Drug Administration. Tobacco Products: Overview: Cigarette Health Warnings. Silver Spring, MD: U.S. FDA, 2011. http://www.fda.gov/TobaccoProducts/Labeling/CigaretteWarningLabels/ucm259214.htm

Abstinence-Only vs. Comprehensive Sexual Education Efficacy in Reducing Teenage Pregnancy Rates in the United States—Lauren Dustin

Teenage Pregnancy Rates in the U.S.

Teenage pregnancy is a public health issue that affects every individual in a community. In 2006, 750,000 teenage girls, aged 15-19, became pregnant. Having a child during teenage years carries many emotional, physical, and financial costs to the parents and community. Teen childbearing costs $9 billion to taxpayers annually, and teen birth rates in the U.S. are up to 9 times higher than most other developed countries. (1) Teens get most information about sex and pregnancy prevention from their school curriculum. About 70% of school districts teach comprehensive sex education that includes information on the risks of sexually transmitted diseases, unintended pregnancies, contraception methods, and abstinence, while other schools teach abstinence-only curriculums. Between the years of 2006-2008, most teens had received information about most of these topics; however, about one-third of teens had not received any formal instruction about contraceptive methods and use. (2) In 2009, there were 39.1 births per 1,000 women aged 15-19, marking an historic low with a decline of 37% from the peak rate of 61.8 in 1991. (3) Although the rate of teenage pregnancy has been steadily declining, there is still a lot more work to be done in finding the most effective educational program.

How Teen Pregnancy is Currently Addressed

Sexual health education is handled in varying ways throughout our nation’s schools. About 35% of school districts in the U.S. believe in abstinence-only education that does not provide any additional information on other methods of prevention from STDs and pregnancy. Discussion of contraception is either prohibited completely, or only permitted in order to emphasize its ineffectiveness. The remaining school districts use comprehensive sex education programs sometimes referred to as abstinence-plus programs. These programs teach abstinence as the most effective method, but also include information and resources on other effective measures of prevention. There have been some shifts in which programs schools prefer, and the biggest change in sex education policies has been toward more schools using abstinence-plus policies. (4)
Abstinence-only education is based on the belief that young men and women are unable to develop committed, loving relationships, and that this leads to childbearing out-of-wedlock. These programs focus on how to develop loving and enduring relationships first before sexual activity. Supporters of abstinence-only programs argue that teaching teenagers about contraception implicitly encourages sexual activity. (5) So instead, abstinence-only education teaches that abstinence is the only way to avoid STDs and pregnancy, and every other method is ineffective. Most programs focus on instilling moral or religious values rather than providing accurate health information. Evaluation of abstinence-only programs found no delay in first sex and analysis of federally funded programs were even found to contain false, misleading, or inaccurate information about reproductive health. (6)

Supporters of comprehensive sex education or abstinence-plus programs say that it may not be reducing sexual activity in teens, but it is teaching them how to do it safely in order to prevent negative outcomes. About half of all teens ages 15-19 are sexually active, and a sexually active teen that does not use contraception has a 90% chance of becoming pregnant within one year. (2) This type of program recognizes the inevitability that most teens are going to be sexually active at some point during their adolescence, and their aim is to prepare them to make healthy and informed choices about contraception. A national survey revealed that 78% of parents of teenagers agree and believe that their children should learn about birth control and safer sex in school. Many medical organizations such as the Institute of Medicine, American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American Academy of Pediatrics also support the inclusion of contraceptive information with abstinence education to prevent teen pregnancy and STDs. (7)

There is no evidence to date that abstinence-only education delays teen sexual activity. However, research shows that abstinence-only strategies may deter contraceptive use and increase a teen’s risk of unintended pregnancies and STDs. (2) A study that compared abstinence-only and abstinence-plus education found that programs offering contraceptive education significantly influenced students’ knowledge and use of contraception methods. The study also found that abstinence-plus education led to increased contraception use by teens at follow-up compared to abstinence-only education. In addition, the use of abstinence-plus programs did not lead to an increase in sexual activity by teens, as mistakenly believed. (7) Evaluations of comprehensive sex education show that they do not increase rates of sexual initiation, they do not lower the age of first sex, and they do not increase the frequency of sexual activity or number of partners. In fact, teens who receive comprehensive sex education have a lower risk of pregnancy than those who receive abstinence-only or no sex education. (8)

New studies have shown that an increase in contraception use, not abstinence, is responsible for the decline in teenage pregnancy rates. According to the Guttmacher Institute, “86% of the decline can be attributed to the use of contraception, while only 14% can be attributed to abstinence.” (9) To reduce rates of teenage pregnancy, programs need to either improve contraceptive behaviors, reduce teen sexual activity, or both. Prohibiting contraceptive education in school-based programs keeps the very information that may have the greatest potential to decrease pregnancy rates from the people who need it the most. However, community attitudes towards teenage sexuality, rather than evidence-based interventions, greatly impact the acceptance of publicly funded school-based sex education programs. (7)

Government funding and policy-making by Congress, and individual state governments provide the basis for which type of education is used in certain school districts. In December 2009, Congress replaced the rigid Community-Based Abstinence Education Program with a new $114.5 million teen pregnancy prevention program to support evidence-based interventions and created the five-year Personal Responsibility Education Program (PREP). Its purpose is to educate adolescents on both abstinence and contraception, and to prepare them for adulthood by teaching subjects such as healthy relationships, financial literacy, and decision-making. Congress also renewed the Title V abstinence-only programs for another five years to provide funding to schools that choose to promote abstinence. (3)

Critique of Abstinence-Only Sexual Education Programs

Although abstinence-only education has not been proven to be effective or ineffective in preventing teen pregnancy in the United States, we can see how these programs have failed to apply social science theories correctly and are flawed in three fundamental ways.

The first major flaw in abstinence-only education programs is that it takes freedom and control away from teenagers when it comes to making decisions about sexual activity. Abstinence is stressed as the only effective method to prevent STDs and pregnancy, and teens are simply told to abstain. There is no information given about other methods of contraception so teens are not even given a choice to make, it is made for them. This type of program fails to consider the Theory of Psychological Reactance and how people react to their freedom being threatened or taken away. The theory says that when a person feels their freedom is being threatened, they experience reactance, a motivational state aimed at restoring the threatened freedom. (10, 11) In other words, they react by doing the negative behavior they are told not to do. When a teen is not given the freedom to make their own choices about sexual activity and contraception and they are simply told not to have sex, they will act out by doing the opposite of what they are told. Since abstinence-only programs do not provide information about contraception, these teens are at a greater risk for STDs and pregnancy because they are less likely to use any form of contraception when they do engage in sexual activity. (7)

Another flaw in abstinence-only education is the use of an improper communicator. These programs use adults, specifically teachers, to convey the message of abstinence as the only option. Teachers are the dominant player in the student-teacher relationship and their dominant and explicit messages can evoke increased psychological reactance. (11) Abstinence-only programs do not take into account the importance of similarity that is stressed in the Communication Theory, and that is also used as a way to reduce reactance and increase compliance. Teenagers who find it hard to relate to adults teaching them about abstinence will resist the very message. One of the most important aspects of the Communication Theory is the use of a messenger that is as similar as possible to the target audience. (12) The use of similarity has been found to reduce reactance and increase compliance. In a study done by Silvia, results showed that similarity increases liking and positive forces towards compliance while reducing negative forces toward resistance. Similarity also increases the communicator’s credibility and reduces the perceived threat to freedom. (10) Teachers and other adults may be the most practical communicator for school-based education, but in reality they are the least similar to the target audience and most likely to evoke reactance.

The last flaw of abstinence-only sex education is that providing inaccurate information or withholding information about contraception is morally and ethically wrong and unsafe. Abstinence is often presented as the moral choice for adolescents contemplating sexual activity. However, the current federal approach to supporting more funding for abstinence-only education raises serious human rights concerns. Access to complete and accurate sexual health information has been recognized as a basic human right and essential to make critical health decisions regarding sexual activity and the prevention of STDs and pregnancy. Abstinence-only programs are problematic because they withhold information and promote sometimes questionable and inaccurate opinions rather than facts. This threatens the fundamental human rights to health, information, and life. (13)

This flaw is a result of the incorrect usage of the Consumer Information Processing Model. This model explains that information is a necessary tool in health education; however, it is not sufficient for knowledge in general. Consumers, or students in this case, tend not to engage in extended searches for information. Therefore, if information about safe sex practices is not given to them in a structured way, they will most likely not seek it out themselves and this puts them in danger of contracting an STD or becoming pregnant if they do not know how to protect themselves. The Consumer Information Processing Model also states that before people will use health information it must be: available, seen as useful and new, and presented in a friendly format. This is where abstinence-only programs are flawed. They do not provide the new, useful, and necessary information in the first place, and the information they do provide, sometimes inaccurate, is not presented in a friendly way. (14)
Without complete and accurate information about sexual health and contraception, teens are unable to make a fully informed decision regarding sexual activity and STD and pregnancy prevention. In fact, teens who only receive abstinence messages face a greater risk of contracting an STD or becoming pregnant because they do not possess the necessary resources on other methods of contraception. (7)

Assessment

The actual causes of teenage pregnancy are not fully understood, but public health professionals would likely argue that a lack of information is a main reason. Teens that are not getting information about contraception and other prevention resources are at an increased risk for negative consequences because they are not informed or prepared to make these important decisions in a safe way. As discussed, abstinence-only sex education programs may be the least effective way to reduce teenage pregnancy rates because they are severely flawed. The explicit, forceful, and dominant messages portrayed by abstinence-only educators are the definition of what evokes psychological reactance in teens. When teenagers are told simply not to do something, they perceive their freedom to be threatened and they react to gain back that freedom by doing that behavior. This is the opposite of what abstinence-only programs want. Additionally, the use of a dissimilar communicator only heightens reactance and resistance to the abstinence-messages. People respond well and tend to comply with the beliefs and messages of a person who is most similar to them, often regardless of how threatening the message is. Lastly, the use of abstinence-only sex education in schools is morally and ethically wrong because they withhold crucial information that can be considered a basic human right in the context of making sexual health decisions. Teens need to be given the information that is new and useful to them because they are likely not going to seek out the information themselves. All of these flaws create inefficiencies that can severely hinder any possible progress made towards lowering the rate of teenage pregnancy.

New Theories

Using the social and behavioral theories previously discussed in the correct way along with several new theories will help to create a new and more effective sexual education intervention. These theories keep the target audience in mind and they recognize the need to reduce reactance in order to be successful. The new intervention will be comprehensive to include information not only about abstinence as the most effective method of STD and pregnancy prevention, but also additional information on other methods of contraception and how to use them.

Limiting Psychological Reactance & the Illusion of Control

Instead of using forceful abstinence-only messages, sex education programs should give the freedom of choice. Don’t tell teens what to do (abstain from sex), tell them what they can do instead (use protection if they become sexually active). Psychological Reactance can be a risk factor for initiation of the negative health behavior so it is important to limit reactance in order for an intervention to be successful in achieving its goal. One way to limit reactance to an intervention is to measure it before starting by finding out if the campaign would elicit reactance in the target audience. Public health professionals can do this through pilot studies or through questionnaires given to teens to assess their attitudes towards abstinence-only versus comprehensive abstinence-plus programs. To avoid reactance we need to know what elements can lead to it. Explicitness, dominance, and reason are three items that can influence reactance. The more explicit or forceful a message is, the more it evokes psychological reactance. When a communicator is perceived to have dominance over the message recipient, this increases reactance as well. However, when reason or support is given for the claim, this is likely to reduce perceived threats and reduce reactance. (11)

The Illusion of Control Theory explains that people value control over their lives or events that happen to them most when they have ownership over that behavior. If public health professionals were to use an intervention that sells control rather than takes it away, this would be accepted much more readily by our target audience. To give teen’s ownership over their sexual health decisions they will value their sexual health and choices they make much more, and this will lead to more informed choices about sex and contraception. The Illusion of Control Theory can also be used to decide when to intervene on a behavior. Intervening during the hot state (when someone is thinking about sexual activity or is already sexually active) will have the greatest effect on helping teens develop realistic plans for sexual activity and the use of contraception. (15)

Communication Theory & the Use of Similarity

The school setting is the most common place where teens learn about sex, both from their teachers and their peers. It is a logical strategy that the adults or teachers of the school system are the ones who educate teens about sex, but perhaps using a more similar messenger would have an additional impact on lowering the teen pregnancy rates. In addition to adults teaching sex education in the classroom, peers can be used to convey messages and information to other teens about contraception and pregnancy prevention in other settings through various forms of media. Interventions can use peers from the same school who are around the same age or even a celebrity who is of similar age.

The Communication Theory and study done by Silvia explains that the most important part of effective communication is to use a messenger that is similar, well-liked, and attractive to the target audience in order to increase compliance and reduce psychological reactance. The messenger should also deliver non-threatening information, unlike the messages in abstinence-only programs. (10, 12) Teens should be given the freedom of choice and control over their sexual health. Using similarity will help to balance positive and negative forces of compliance and reactance and give teens the confidence and freedom to make their own decisions about their sexual health. Providing the resources will enable them to make safer choices and help to decrease the teen pregnancy rate.

Bringing About Change with the Agenda Setting Theory

To learn from the flaws of abstinence-only programs and to eventually eliminate these programs all together I would propose using the Agenda Setting Theory. This theory is based on the idea that there is a public agenda, and it consists of what people are talking about and what people are interested in at that specific moment in history. If you can get people to think and talk about your issue, it will be a part of the public agenda and it will be much easier to have an impact on the public health issue. Public health professionals can use this theory to get people to realize the flaws with abstinence-only programs and why comprehensive programs can be more effective and safer for teens. This would tie in very well with the use of a media campaign targeting teens because often times the media dictates the public agenda. (12)

New Intervention

The first strategy towards creating a more effective sexual education intervention program that reduces the rate of teenage pregnancy in the U.S. would be to make all education programs comprehensive. I believe having comprehensive sex education as the primary form would be the most effective in increasing contraception use, and reducing STDs and pregnancy rates in teens age 15-19 as previously supported. (7) Information about safe sex and contraception is critical to teenagers who are faced with decisions about sexual activity. To withhold this information puts them at greater risk for negative consequences. The new intervention will offer control and freedom to the teenagers so as to not threaten them and evoke psychological reactance. Instead of explicitly stating that abstinence is the only way to go, the new intervention will feature other choices for contraception and prevention, in addition to abstinence. This has shown to be more effective in increasing the use of contraception, which in turn leads to a decrease in pregnancy rates. (9) The most effective curriculum-based programs have focused on a specific behavior, such as using contraception, and provide the basic information, not too much detail . They are age appropriate and based on theoretical approaches; they address peer pressure, and teach skills in problem-solving and decision-making to prepare students for difficult life choices they will encounter. Teaching basic life skills along with sex education has shown to be effective in increasing knowledge and changing attitudes and behavior towards contraception. (16, 17)

To give teens the freedom to choose how they handle their sexual health may not be enough to achieve the overall goal of reducing teen pregnancy. For this reason, the new intervention will also add another communicator to the program who is more similar to the target audience to deliver messages to teens. On top of the comprehensive school curriculum, the program will feature media ad campaigns emphasizing safe sex and “the choice is yours” type statements. The campaign will be marketed like a mass movement, urging teens to join the “Safe Sex” movement by choosing to abstain or use contraception, and realizing they have the freedom to choose and they have control over their sexual health decisions and the consequences of those decisions. By joining a movement, this will make the teens feel like they truly are in control and they will not feel threatened to obey abstinence-only messages. These messages will be delivered by someone who is familiar and similar to the target audience. Studies by Silvia show that similarity increases compliance and decreases resistance. This will have the greatest effect on getting teens to use contraception in order to reduce the teen pregnancy rates. (10, 12) Teens can relate to someone who is most similar to themselves, and this is not going to be the teachers or adults in a school. A peer-to-peer media campaigns will be a more effective element to the comprehensive sex education already in place.

The intervention will feature positive and freedom enforcing messages on posters throughout the schools, on computers, on school news broadcasts, on local television, and social networking websites. The campaign will say things like “Safe sex is sexy”, “The choice is yours, own it” and other positive, non-dominant messages. Teens say that they would prefer to get information about sex from their parents, but more than half of them report getting information about sex, birth control, and pregnancy from television shows, movies, and magazines. (18) Because teens most often learn about sex through these channels of communication, using magazines and local television would successfully reach the target audience. The messages will be created and delivered by peers and persons who are the most similar to the target audience such as students from the same school. The combination of control and the use of a similar communicator will greatly reduce reactance and increase compliance. (10)

Summary

Although many school-based and community interventions have been used to try to reduce the rate of teenage pregnancy in the U.S., most have been ineffective. The designs of abstinence-only programs are especially flawed because they evoke psychological reactance from the dominant and forceful messages they portray. They fail to provide the necessary information about contraception that teens need in order to make safe decisions about their sexual activity. Teens that do not receive information about contraception are at an increased risk for getting and STD or becoming pregnant. Educational programs that are comprehensive in nature and include information on both abstinence and other methods of prevention, as well as teach important life skills, are the most successful at increasing knowledge and changing attitudes and behavior. Teens respond best and tend to comply more with messages that use a communicator that is most similar to them. Interventions that take advantage of similarity effectively limit reactance while increasing compliance. This will have a positive effect on reducing the teen pregnancy rate in the U.S. The first step in creating a more effective sexual education program for all school districts to use is to get this issue on the public agenda through the use of the media. This intervention will depend on public support and community acceptance in order to be successful, and this will be the most difficult element to achieve.

References
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2. Facts on american teens' sexual and reproductive health. (2011, August). Retrieved from http://www.guttmacher.org/pubs/FB-ATSRH.html
3. Facts on american teens' sources of information about sex. (2011, February). Retrieved from http://www.guttmacher.org/pubs/FB-Teen-Sex-Ed.html
4. Landry, D. J., Kaeser, L., & Richards, C. L. (1999). Abstinence promotion and the provision of information about contraception in public school district sexuality education policies. Family Planning Perspectives, 31(6), 280-286. Retrieved from http://www.jstor.org.ezproxy.bu.edu/stable/pdfplus/2991538.pdf?acceptTC=true
5. Rector, R. (2002, April 8). Effectiveness of abstinence education programs in reducing sexual activity among youth. Retrieved from http://www.heritage.org/research/reports/2002/04/the-effectiveness-of-abstinence-education-programs
6. The Content of Federally Funded Abstinence-Only Education Programs. (2004, December). Retrieved from http://www.apha.org/apha/PDFs/HIV/The_Waxman_Report.pdf
7. Bennett, S. E., & Assefi, N. P. (2005). School-based teenage pregnancy prevention programs: A systemcatic review of randomied controlled trials . Journal of Adolescent Health, 36(1), 72-81. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X04001673
8. Kohler, P. K., Manhart, L. E., & Lafferty, W. E. (2008). Abstinence-only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of Adolescent Health, 42(4), 344-351. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X07004260
9. U.s. teenage pregnancies, births, and abortions: National and state trends and trends by race and ethnicity. (2010, January). Retrieved from http://www.guttmacher.org/pubs/USTPtrends.pdf
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11. Dillard, J. P., & Shen, L. (2005). On the nature of reactance and its role in persuasive health communication. Communication Monographs, 72(2), 144-168. Retrieved from http://classweb.gmu.edu/gkreps/820/009.pdf
12. Shaw, E. F. (1979). Agenda-setting and mass communication theory. Retrieved from http://xa.yimg.com/kq/groups/22925642/1944236267/name/Shaw- Agenda-Setting and Mass Communication Theory.pdf
13. Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: A review of u.s. policies and programs. Journal of Adolescent Health, 38(1), 72-81. Retrieved from http://www.sciencedirect.com.ezproxy.bu.edu/science/article/pii/S1054139X05004672
14. Campbell, C. (2001, August 21). Health education behavior models and theories: A review of the literature part i. Retrieved from http://msucares.com/health/health/appa1.htm
15. Langer, E. J. (1975). The illusion of control. Journal of Personality and Social Psychology, 32(2), 311-328.
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Milwaukee Campaign Against Sleeping with Baby – Natasha Neal

Infant Mortality in Milwaukee, Wisconsin
Milwaukee, Wisconsin has higher rates of infant mortality in comparison to other areas of the United States and other parts of the world. Infant mortality is the number of infants that die during their first year of life (1). Milwaukee’s African-American infant mortality rate is ranked higher than at least 35 other countries, including some developing countries (2). The top four reasons for infant death in Milwaukee are complications of prematurity; congenital abnormalities and related complications; sudden infant death syndrome (SIDS), overlay, and accidental suffocation; and infections (2). In particular, Wisconsin is a state with one of the largest differences in infant mortality based on race. The gap between non-Hispanic white infants and African-American infants is quite large: for every five white infants that die prematurely, 14 African-American babies die (1). Based on the list of most common deaths in infants, the only cause that is preventable after birth is SIDS, overlay, and accidental suffocation.

In order to address the dismal situation, the City of Milwaukee’s Health Department created a Safe Sleep Awareness Campaign, in which they discourage the practice of co-sleeping, and more specifically, babies and adults sharing the same bed (3). They have used posters, as well as radio and television advertisements to get their point across to the public. To view the public health campaign advertisements, visit http://city.milwaukee.gov/SafeSleep (3). The public has perceived these advertisements with mixed views as they depict a small baby sleeping in a bed next to a large knife. The poster states: “Your baby sleeping with you can be just as dangerous.” Some responses have been supportive towards catching parents’ attention on an important matter; however, others feel that the City of Milwaukee is demonizing parents. These posters were created with the intention of grabbing the attention of parents that may bed-share. It is very unlikely that parents that co-sleep are consciously putting their babies in harm’s way, explaining the negative reactions of some parents.

Problems with Milwaukee’s Campaign Against Co-Sleeping

Despite correctly identifying the large racial disparity in infant mortality, Milwaukee’s campaign is unlikely to be successful in closing this gap. The Health Department has chosen to focus on a much narrower health behavior in the hopes that it will significantly reduce the rates of infant mortality. The advertisements used in the campaign overlook four important social behavioral models: Labeling Theory, Optimism Bias, the Law of Small Numbers, and Psychological Reactance. Furthermore, The City of Milwaukee’s Health Department has done a poor job of approaching such a controversial, and poorly understood health behavior.

The Health Department has been quick to pinpoint bed-sharing as the form of unsafe sleeping practice that results in sudden infant death syndrome (SIDS) or sudden unexpected death in infancy (SUDI). However, based on a study released in 2011, the major risk factors for SIDS also include inadequate prenatal care, low birth weight, premature birth, short interval between births, and maternal substance abuse (4). It becomes clear that many of these factors are uncontrollable, and are often completely independent from whether an infant sleeps in the same bed as an adult or not, except for maternal substance abuse. Therefore, even infants that sleep in their own bassinet or crib are at risk of SIDS. In some unfortunate cases, despite parents following the safest child-rearing practices, an infant will still experience SIDS. In combination with the disparity in infant mortality between races, it encourages one to question whether an ethnic community in particular is engaging or has a history of increased risk factors, in addition to bed-sharing. It is important to examine the situation in relation to different races as one of the goals is to narrow the gap between infant mortality rates in Milwaukee.

Data included in the City of Milwaukee’s Fetal Infant Mortality Review (FIMR) also does not concretely support their view on targeting co-sleeping. The FIMR stated that Singapore had the lowest infant mortality rates, despite approximately 70% of the population engaging in bed-sharing, showing that bed-sharing can be practiced safely (5). Armed with this knowledge, one must ask what specifically, during bed-sharing, is the cause for increased infant mortality in the United States versus Singapore. Research has been conducted on this point, and it has been found that there are often other factors playing a role. For instance, the risk of infant death during bed-sharing often occurs if a parent also engages in smoking or alcohol abuse (6). In addition to this, in other countries where bed-sharing is the predominant form of sleep practice, it is important to be aware that in these countries, families often sleep on firm mats instead of softer mattresses (7). Therefore, it is a combination of the risks mentioned previously, including premature birth and maternal substance use, combined with bed-sharing, that can increase the risk of infant death.

Another critical consideration of this intervention is the message that public health officials want to send. Research has shown that the risk of SIDS increases when babies sleep in a different room from parents (8). Despite this known fact, the advertisements do not include information indicating that although bed-sharing should not occur, room-sharing is important to the health of infants. The advertisements, while depicting the dangers of bed-sharing, contain little information on how to mitigate the risks. This information only appears on the website, and yet there is no guarantee that parents will spend the time going to the website. All information must easily reach parents in order for individuals to make educated decisions. The City of Milwaukee also ignores the positives that have been identified in literature regarding bed-sharing. These positive elements include making breastfeeding easier, allowing babies and parents to get more sleep, ensuring mothers are more responsive to the needs of the infant, and the practice encourages bonding and security between parent and infant (7). By purposely omitting this information, the public may feel as though the City of Milwaukee’s Health Department is trying to deceive or manipulate their behavior. This may be especially likely to occur in parents that are well-versed in the sleeping practices of other non-Western cultures.

Due to the vast majority and somewhat contradictory information available in regards to bed-sharing and co-sleeping, it becomes apparent that education must be the first step to behavior change. Parents are unaware of the pros and cons of different sleep practices. As well, many parents are misinformed about the definition of co-sleeping; some believe that co-sleeping is defined specifically as the practice of sharing the same bed with a baby; however, this is not true (3). Having a baby sleep in a bassinet or crib next to the parents’ bed is also a form of co-sleeping. Some experts have begun referring to room-sharing versus bed-sharing in order to clarify the difference in the two practices (3). One problem with the campaign is that the ads do not clarify this distinction. Therefore, the overall impression parents may be getting is that their babies need to sleep in a completely different room.

Labeling Theory and Racism's Effect on Health Disparities

Milwaukee’s Health Department has been quick to identify the difference in infant mortality rates between African Americans and non-Hispanic whites (2). However, one major flaw in their intervention was the obvious avoidance of addressing these differences in their campaign, other than including two versions of their ads, one featuring a white infant and the other featuring an African-American infant (3). It is important to consider the reasons behind why the rates of infant mortality differ so drastically between the two races, even when all other factors are similar. It has been reported that an African-American woman with a college degree has poorer infant mortality rates compared to a white woman with only a high school education (1). One contributing factor to this phenomenon may be due to labeling theory, and its relation to race. Institutionalized racism may play a huge role in the differences in infant morality rates between white and African-American infants. Differences in race are especially important as the City of Milwaukee is dramatically racially segregated (9).

One study has looked at biological differences between people of different races in order to determine reasons for such dramatic differences in health disparities in different populations of people. One study was conducted in order to identify why blood pressure can differ so drastically between black and white individuals (10). Researchers Krieger and Sydney concluded that when examining blood pressure, it was important to take into account how discrimination may affect health (10). Similarly, it is important to take into account the biological differences of African-American women in comparison to white women. African-American women typically have babies with lower birth weights and are more often born prematurely (9). Institutional racism, a form of racism that is not necessarily obvious, can result in African-American women having increased stress levels, perhaps due to the expectation that discrimination will occur in everyday life events (11). Increased stress levels may then lead to increased risk of premature births and low birth weight. It is important to help these women that must live with institutional racism overcome the hardships they may face, especially during pregnancy.

One other study looked at the differences in infant mortality between African-Americans and white mothers in relation to sleeping position. The study identified that the sleeping positions varied distinctly between the two races. African-American infants were more likely to sleep in the prone position, or on their stomachs, rather than the nonprone position (on the back or side) (12). The prone position is more highly associated with SIDS. This could be one reason why the disparity in infant mortality exists between the two races. The study also went on to find that African-American mothers more often recalled or were incorrectly told by health professionals that the prone position should be used (12). Here we see a form of institutionalized racism that impacts the mothers of different races, as it is unlikely physicians were purposely suggesting unsafe sleeping practices.

A separate study found that interpersonal racial discrimination experienced by African-American women a year prior to birth as well as over a lifetime was a risk factor for premature birth (13). Nancy Krieger defines interpersonal racism as “directly perceived discriminatory interactions” (14). The City of Milwaukee should consider examining whether members of the African-American community experience higher levels of interpersonal racism, in order to prevent this from occurring. In the study conducted by Rankin, David, and Collins, they found that using active coping behaviors to deal with interpersonal racism could weaken the association between the risk factor and premature birth (13).

Understanding the differences between African-American women and white women is one way to focus Milwaukee’s intervention and an important factor in determining how to reduce the infant mortality rate. Milwaukee’s campaign does not inform women that babies born prematurely or with low birth weights are at higher risks for SIDS, and the necessity to take more precautions. The racial segregation in Milwaukee can further impact the situation as areas with high populations of African-Americans may have fewer resources for pregnant and new mothers, such as clinics, primary care offices, and prenatal classes.

Optimistic Bias and the Law of Small Numbers

The Health Department has overlooked the roles that the theory of optimistic bias in combination with the law of small numbers may play in this campaign. The Law of Small Numbers is the theory that people will often associate their risk with one positive case despite substantial information contradicting this (15). For example, a smoker will doubt that smoking increases the risk of cancer despite the vast evidence supporting this simply because they have a family member who smoked their entire life and never developed cancer. Optimism bias refers to the fact that an individual will know the risks of a particular behavior, but will underestimate their own risk (16). The campaign against bed-sharing emphasizes the dangers through the use of the knife and tombstones in the ads (3). While this may communicate the risk of bed-sharing with the public, individuals may believe that they will be the exception to the statistics. In the television ad depicting a mother that tosses and turns while sleeping, the overall impression is that bed-sharing may lead to a parent or adult suffocating their child. However, based on optimistic bias, people viewing the ad may think that while suffocation of a child may happen to others, it will not happen to them – they will be the exception to the rule (16). This becomes especially important for parents who already have had a child, and who practiced bed-sharing without any incidence of SIDS or SUDI. Based on their previous experience, they are likely to experience the law of small numbers, and be confident they can bed-share with smaller risks than the general public, although this may not necessarily true (17). Another factor to consider is the social networks of people, and the different sleeping practices friends and families engage in. One study found that at 2 weeks of age, 42% of parents shared a bed, at 3 months 34% shared a bed, and 28% at a year of age (18). These statistics show that bed-sharing is not rare and many people likely know of other parents that sleep in the same bed as their infants. The knowledge of others that have bed-shared successfully can lead people to believe in the Law of Small Numbers - that those people that have successfully practiced bed-sharing are in fact the norm. These individuals will question the veracity of the ads in conjunction with having an increased risk of infant death, especially if these parents believe that bed-sharing is a better parenting technique. Combined with optimistic bias, knowing others that successfully bed-share make it unlikely that these ads will be effective in changing the behavior of parents that co-sleep in the same bed, especially those that have never known someone whose child suffered from SIDS or SUDI.

Psychological Reactance and Pushback Against the Ads

It is very important to gauge how the public perceives the advertisements. Psychological reactance occurs when people feel their control is being taken away (19). It becomes particularly important in the issue of co-sleeping because parents have differing opinions on the pros and cons of bed-sharing based on the literature available and the cultural norms of different populations. Therefore, when advertisements tell people that their method of child-rearing is incorrect or unsafe and should not be practiced anymore, it is in effect taking away the freedom for people to decide how they want to raise their children, and what they believe is best for their child’s development. In a study conducted, investigators found that countercultural parents in the US were more likely to also be “pronatural.” This group of parents was interested in following “natural parenting” and often follows practices more common in non-Western countries, such as breast-feeding rather than formula use, bed-sharing, and using only organic foods (20). However, they may be unaware that in non-Western countries, firmer mats instead of softer mattresses are used. These parents believe that they are practicing the best form of parenting, and will therefore not heed the warning, and they will perceive a loss of control over their style of parenting. When people experience psychological reactance, they will often engage in the prohibited behavior much more strongly (19).

Solutions for Co-Sleeping and High Infant Mortality Rates

It is important to consider the root causes of high infant mortality. Despite perhaps not being the largest cause of SIDS and SUDI, proper co-sleeping may lower the rates of infant mortality in Milwaukee. However, identifying the differences in racial groups will also be impactful if addressed in the intervention. A new intervention is being proposed that will effectively remove the barriers in the already existing intervention.

The new intervention will consist of various different platforms: it will use television advertisements as well as offering educational programs in the community. This new intervention is based largely on three models useful for changing behavior: the Theory of Planned Behavior, Social Expectations Theory, and Advertising Theory. In combination, these will overcome the problems seen in Milwaukee’s current campaign, and will hopefully reduce the number of deaths that can be attributable to unsafe sleeping practice, as well as reducing the number of SIDS and SIDU deaths in general in Milwaukee.

New television advertisements will be created for the intervention. The advertisements will depict images of the important milestones in a child’s life: first birthday, first steps, first day of school, graduation, marriage, and then the birth of a grandchild. Following the images, a parent who experienced the death of an infant due to SIDS or SIDU will speak out. More specifically, the parent will emphasize the point that they were unaware of the importance of safe-sleep practices, that they missed out on so many of the milestones they expected to experience, and they will encourage parents to seek out new information regarding safe sleep practices. They will also suggest ensuring children sleep in an environment without blankets or pillows, to avoid the risk of suffocation, and that parents always place their babies on their back or supine position to sleep (8). If parents are concerned about moving in their sleep, the ad will go on to explain that the safest place for a child is in a crib or bassinet. However, it will emphasize the importance of infants sleeping in the same room as a parent.

In addition, the new intervention will have nurses available at churches, clinics, or community centers for expecting and new mothers. These nurses will be concentrated in African-Americans communities, where clinics and services may be harder to come by and where infant mortality rates are much higher – in particular, the zip codes of 53206, 53210, and 53233, which have the highest rates of infant mortality in Milwaukee (2). The nurses will act as educators, talking about the increased risk of SIDS for premature or low birth weight babies. They will ensure that African-Americans have strategies in place to deal with any type of discrimination they may face. They will describe common safe sleep practices outlined in the report by the American Academy of Pediatrics, such as always placing an infant in a supine position, using a firm mattress, avoiding pillows and blankets near the infant, encouraging breast-feeding, encouraging room-sharing over bed-sharing, and encouraging the avoidance of exposure to tobacco smoke, alcohol, and illegal drugs (8).

Finally, the City of Milwaukee should start a program where parents can donate cribs or bassinets once they are no longer needed. These will be provided to parents of newborns that are interested in room-sharing rather than bed-sharing, but that may not have the means to purchase these items.

Social Expectations Theory for Community-Based Interventions

The Social Expectations Theory suggests the importance of examining individuals based on the community they live in and the values they hold (21). As Milwaukee is racially segregated, this theory would be very helpful in addressing the differences in community norms and values. This theory, and its examination based on a community level, will help overcome weaknesses due to the Labeling Theory and racism. Do mothers in the African-American communities place more importance on bed-sharing or sleeping in the prone position? Does this belief stem from the norms and values of their culture? Is there a way to educate these mothers on safer methods of co-sleeping that may reduce risk of smothering and suffocation?

It is also important to focus on the issue of infant mortality among African-Americans in general, as this population has the highest rates of infant mortality in the city. The first step would be to identify the resources available to new and expecting mothers. Placing more resources in these lacking communities may have a profound effect on infant mortality. Finally, it will be important to examine the communities, and in particular, the African-American communities, for indicators of excess stress levels mothers may encounter due to discrimination and racism. If these two issues can be combatted, perhaps the number of premature or low birth weight cases will decrease. Following this identification, if the City of Milwaukee can take a more active role in the resources available to pregnant women combatting discrimination, perhaps Labeling Theory and racism can be overcome, in turn decreasing the number of cases of premature and low birth weight babies, and in turn decreasing the number of cases of SIDS or SIDU.

The Theory of Planned Behavior

The first step to effecting behavior change, especially in regards to a topic that individuals may not be familiar with, is education. Using the Theory of Planned Behavior, one can begin to develop a new intervention that may be more effective in reaching people that currently do not practice safe sleep techniques. The Theory of Planned Behavior is based on the fact that individuals weigh their attitudes and social norms against expected outcomes when engaging in a particular action (22). An important factor is their perceived behavioral control, also known as self-efficacy, in carrying out a particular behavior (22). This theory, with a focus on education, can be used to overcome optimism bias and the law of small numbers. In order for this to occur, it is imperative that individuals are educated on the safest sleeping practices for children from birth to the age of one.

If prenatal classes are available in the community and are well attended, the City of Milwaukee should ensure that expectant mothers are educated about safe sleeping practices during these classes. This allows mothers to be exposed to the information, and they can include it during their decision process. If prenatal classes are not offered, programs will be created in churches, community centers, and clinics in the community, which will be free of charge. By basing these educational events in a group setting, new social norms are being created around safe sleeping practices. These safe-sleeping practices can be geared towards room-sharing over bed-sharing.

The information presented in the sessions will include information about the pros of co-sleeping, the definitions of co-sleeping, room-sharing, and bed-sharing and the pros and cons of each. Classes will encourage parents to use bassinets or cribs that can be close to the bed, which are completely empty except for the mattress. For parents that are determined to bed-share, it is important to portray a safe way to do so – by placing blankets and pillows away from infants, by placing infants on their backs to sleep, and by ensuring that the parents are not restless sleepers that tend to move in their sleep. It is important, on the part of the educators, not to give the impression that parents are being told how to raise their children. By using education rather than commanding or ordering parents to engage in a particular behavior, we are allowing parents to make their own decisions on child-rearing practices. This will help mitigate psychological reactance because we are not taking away individuals’ sense of control (19). Instead, we are giving control to parents – they are now in control of making safe and smart decisions when choosing a particular sleep practice based on all of the information available.

One important addition to the Theory of Planned Behavior is the component of self-efficacy (22). Parents must be made to feel as though they can actually change their behavior and be successful. One barrier to self-efficacy in the context of room-sharing may be that the parent does not have access to a bassinet or a crib, due to financial circumstances. Therefore, this needs to be addressed in the intervention. It is unreasonable to institute a campaign encouraging mothers to practice safe-sleeping techniques if they are unable to afford the necessary requirements. The program involving crib and bassinet donations from the public will allow parents to obtain these needed items when financial limitations exist. By using donations, Milwaukee’s Health Department will not need to worry about financial constraints.

Advertising Theory and Connecting to the Community

Advertising theory should be considered when reaching out to the target population. Advertising theory is composed of three main components: the promise, core values, and support. These work together to reach the public on an emotional level (23). Therefore, advertisements need to be created which touch individuals on all three components. The promise the new set of advertisements will offer to viewers is the possibility of being a part of all important milestones in a child’s lifetime: first steps, first birthday, graduation, wedding, and the birth of their first child. These are all experiences that parents will treasure over the course of their child’s life, and will reach a wider target. These images will support the promise of experiencing life’s many milestones, and will play on the values of love, family, and aspirations. In order to overcome the law of small numbers, following the images, a parent will speak about how they missed out on all of these important life events because they were unaware of safe sleep practices, and therefore, they suffered the death of a child. They will show a picture of their baby that passed away due to SIDS. This overcomes the law of small numbers because people can now relate to someone who has experienced SIDS rather than knowing someone that has successfully bed-shared. Advertising Theory has proven successful in an intervention known as the Truth Campaign in Florida (24). This campaign was able to build a brand based on values, and resulted in decreased rates of high school and middle school students smoking (24). Similarly to this campaign, Milwaukee’s safe-sleeping campaign will place most attention on life’s important milestones for a parent, and the values of love and family, in order to connect with parents and change behavior.

Conclusion

Milwaukee is a city that is unique in its mortality rate differences based on ethnicity. It is critical to narrow the gap, and decrease the infant mortality rate. Milwaukee has correctly identified one potential area that may reduce the rates of infant mortality – the incidence of bed-sharing, but by basing their intervention on fear alone, they are unable to make an emotional connection with viewers that will encourage parents to change their behavior. Using the Social Expectations Theory, The Theory of Planned Behavior, and Advertising Theory for the basis of a new intervention, Milwaukee will be more successful in reaching their target population, and lowering the rates of infant mortality due to SIDS and SIDU.

References:
1. City of Milwaukee. Infant Mortality. Available at: http://city.milwaukee.gov/InfantMortality.htm. Accessed December 12, 2011.
2. City of Milwaukee Health Department. 2010 City of Milwaukee Fetal Infant Mortality Review (FIMR) Report: Understanding and Preventing Infant Death and Stillbirth in Milwaukee. Milwaukee, Wisconsin: City of Milwaukee Health Department; 2008.
3. City of Milwaukee Health Department. Safe Sleep for Your Baby. City of Milwaukee. Available at: http://city.milwaukee.gov/SafeSleep. Accessed December 14, 2011.
4. Athanasakis E, Karavasiliadou S, Styliadis I. The factors contributing to the risk of sudden infant death syndrome. Hippokratia. 2011;15(2):127-131.
5. Chng SY. Sleep disorders in children: the Singapore perspective. Ann. Acad. Med. Singap. 2008;37(8):706-709.
6. Lahr MB, Rosenberg KD, Lapidus JA. Bedsharing and maternal smoking in a population-based survey of new mothers. Pediatrics. 2005;116(4):e530-542.
7. Prato CC. The Family Bed: The Risks and Rewards of Co-Sleeping. Parenthood.com.
8. Task Force on Sudden Infant Death Syndrome. SIDS and Other Sleep-Relatd Infant Deaths: Expansion of Recommendations for a Safe Infant Sleeping Environment. AAP. 2011;128(5):1341-1367.
9. Sims M, Rainge Y. Urban poverty and infant-health disparities among African Americans and whites in Milwaukee. J Natl Med Assoc. 2002;94(6):472-479.
10. Krieger N, Sidney S. Racial discrimination and blood pressure: the CARDIA Study of young black and white adults. Am J Public Health. 1996;86(10):1370-1378.
13. Harrell SP. A Multidimensional Conceptualization of Racism‐Related Stress: Implications for the Well‐Being of People of Color. American Journal of Orthopsychiatry. 2000;70(1):42-57.
14. Hauck FR, Moore CM, Herman SM, et al. The contribution of prone sleeping position to the racial disparity in sudden infant death syndrome: the Chicago Infant Mortality Study. Pediatrics. 2002;110(4):772-780.
11. Rankin KM, David RJ, Collins JW Jr. African American women’s exposure to interpersonal racial discrimination in public settings and preterm birth: the effect of coping behaviors. Ethn Dis. 2011;21(3):370-376.
12. Krieger N. Embodying inequality: a review of concepts, measures, and methods for studying health consequences of discrimination. Int J Health Serv. 1999;29(2):295-352.
15. Tversky A, Kahneman. Belief in the Law of Small Numbers. Psychological Bulletin. 1971;76(2):105-110.
16. Davidson K, Prkachin K. Optimism and Unrealistic Optimism have an Interacting Impact on Health-Promoting Behavior and Knowledge Changes. Personality and Social Psychology Bulletin. 1997;23(6):617 -625.
17. Weinstein ND. Unrealistic optimism about susceptibility to health problems: conclusions from a community-wide sample. J Behav Med. 1987;10(5):481-500.
18. Hauck FR, Signore C, Fein SB, Raju TNK. Infant sleeping arrangements and practices during the first year of life. Pediatrics. 2008;122 Suppl 2:S113-120.
19. Brehm J. Psychological Reactance: Theory and Applications. ACR. 1989;16:72-75.
20. Weisner TS. Culture, Development, and Diversity: Expectable Pluralism, Conflict, and Similarity. Ethos. 2009;37(2):181-196.
21. Flamand L. Social Expectation Theory | eHow.com. eHow. Available at: http://www.ehow.com/about_5474324_social-expectation-theory.html. Accessed December 13, 2011.
22. Icek A. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991;50(2):179-211.
23. Evans WD, Hastings G. Public Health Branding. Oxford University Press; 2008. Available at: http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780199237135.001.0001/acprof-9780199237135. Accessed December 14, 2011.
24. HIcks J. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001;10:3-5.

Why We Are Not Getting Through to Teens: A Critique of the ‘Every 15 Minutes’ Program — Sarah Baird

Whether it is realistic to expect teens to wait until they turn 21 to drink alcohol is debatable, but one thing is certain—some teens do drink. Teenage drinking is a risky behavior that 71% of high school seniors have participated in at least once and 41.2% report drinking within the last month (1). The prevalence of underage drinking combined with the fact that motor vehicle fatality is the leading cause of death amongst teens, has spurred many anti-drunk driving programs, some more successful than others (2). When I was in high school, my school chose the ‘Every 15 Minutes’ program to sell the “don’t drink and drive” message. ‘Every 15 Minutes’ is a worldwide, school based, anti-drunk driving intervention. The origins of the program date back to 1995 when the Chico Police Department developed this two-day intervention (3). The program’s name was coined from an early 1990’s statistic that someone in the United States dies every 15 minutes from an alcohol-related collision (3).

When a high school chooses to host this program, it involves the participation of community members such as law enforcement, paramedics, hospital staff, coroners, and funeral homes, in addition to actual high school students and staff members (4). Several students are chosen to participate in the intervention and on day one a “grim reaper” pulls one of the selected students out of class every fifteen minutes, their obituary is read, and they return to class as the “living dead” unable to communicate with their fellow classmates (4). A drunk driving collision is then simulated on school grounds with students watching. The simulation is intended to be as realistic as possible. Emergency response teams attempt to rescue injured students, some students are pronounced dead on scene and others are rushed away by ambulance, police officers administer sobriety tests to the drivers and they are booked on drunk driving charges (4). In order to simulate the separation from friends and family that occurs with death or jail time, the students who participate in the collision retreat to a hotel for the night (4). Day two involves an assembly with a video presentation of the previous day’s events and reflections from participants. The students who played a part in day one read letters addressed to their parents as if they actually died and parents read similar letters addressed to their children (4). A parent who actually lost a child in an alcohol-related collision will speak to the student body along with hospital staff and police officers (4). The program is intended to be dramatic and evoke strong emotions, provoking students to think about the consequences of their actions. A video showing this intervention in further detail can be seen on the ABC news program Good Morning America: Every 15 Minutes (5). Despite the widespread use of this intervention at high schools across the country, ‘Every 15 Minutes’ is flawed and unsuccessful in effecting change in teens’ behavior.

The Danger of Expectations
The expectation established by this intervention is one of the major downfalls of this program. The entire program is represented under the idea that a tragic death occurs every 15 minutes as a result of an alcohol-related crash. In reality, 10,839 deaths occurred in 2009 as a result of alcohol-impaired driving collisions, which translates to one death every 48 minutes (6). Alcohol-related driving fatalities have declined in recent years, but even when this program first began in 1995 there was one alcohol-related crash on average of every 30 minutes (7). From the start, the foundation of this intervention was based upon an incorrect statistic. While the ‘Every 15 Minutes’ website does acknowledge the number of individuals killed in alcohol-related crashes has decreased, an updated statistic is not referenced (4).

The inflated statistic is of concern for multiple reasons—one being that the ‘Every 15 Minutes’ message is increasing the perception of the prevalence of the problem. The message causes students to overestimate the norm of drinking and alcohol-related fatalities. Researches have linked the failure of the anti-drug campaign DARE to this same flaw, criticizing the program for making drugs seem too “normal” and misrepresenting the prevalence of drug use (8). Social norms are often a strong predictor of behavior and this correlation is explored by social norms theory, which is based on the principle that people incorrectly perceive the behaviors and attitudes of others to differ from their own (9). Perkins and Berkowitz first suggested what is now social norms theory in 1986 and have done extensive research of social norms relating to student alcohol use (9). Studies of this theory have shown individuals often overestimate the prevalence of risk behaviors and change their own behavior to conform to the perceived norm (10). Additionally, those who partake in risky behaviors use the misperceived norm to rationalize or justify their unhealthy behavior (10).

Applying social norms theory to ‘Every 15 Minutes’ suggests students will drink and drive and possibly justify their behavior because they misperceive their peers to be tolerant of and partaking in the behavior themselves. Social norms theory also implies students could feel uncomfortable speaking out against drinking and driving because they misperceive their peers to be drinking and driving at a greater rate than reality would dictate. Research has consistently found that students considerably overestimate the prevalence of heavy drinking and drunk driving (11). Perkins suggests interventions aimed at dispelling misperceptions can reduce problem drinking through empowering responsible students and restraining those who partake in the risk behavior (11). The ‘Every 15 Minutes’ program does the exact opposite, creating a negative cycle where risk behaviors are perpetuated and healthy behaviors are suppressed (10). Thus, the expectation of this intervention perpetuates an existing misperception, making the misperception reality.

Provoking Reactance
The overarching message of ‘Every 15 Minutes’ could be summarized as “don’t drink and drive or else.” Ideally teens would never choose to drink and drive, but the choice exists. This intervention removes that choice without offering much of an alternative. The program’s message is not only simplistic, but the domineering tone also threatens teens’ freedom.

The fear appeal structure of ‘Every 15 Minutes’ poses a threat to teens’ freedom. The standard fear appeal structure involves threat-to-health and threat-to-freedom components (12). The threat-to-health component is substantiated through the physical and emotional consequences, fake injuries and death, and statistics on alcohol-related fatalities. The threat-to-freedom component is validated through the staged prosecution and punishment, and idea that the only option is to abstain from drinking and driving. Health promotion messages that utilize strong threats to health and freedom have been associated with increased reactance (12). Under Brehm’s theory of psychological reactance, when free behaviors are threatened or eliminated, people experience a motivational state to reestablish those freedoms (12). Specifically, Brehm defines reestablishing freedoms as participating in the behavior that one has been told they cannot or should not participate in (13). Individuals will act to restore freedoms through any available means and their level of reactance is proportional to their value of the lost freedom (12). It is also of note that individuals may or may not be aware they are experiencing reactance (12).

Under the principles of the psychological reactance theory, telling teens ‘no’ could motivate them to say ‘yes’ and ‘Every 15 Minutes’ does just that. The program uses scare tactics to emphasize drinking and driving is a big problem with drastic consequences, which teens are at risk of, and in the face of this immense threat the underwhelming answer is—just do not drink and drive. Students walk away from this intervention knowing what they are not supposed to do, but not much else. The only solution offered up by the intervention is to act responsibly—a paternalistic message often hammered into teens. Looking back on our teen years we all know this is easier said than done. The “Just Say No” approach did not work for DARE and the equivalent message does not work here (8). Reactance is minimized when someone familiar and relatable delivers the message, which this intervention partly does, but the message is just too simple here to be effective (14). This theory also explains that those most likely to engage in the free behavior that is being threatened exhibit the highest degree of reactance (13). Thus, students that are most likely to drink and drive are also most likely to feel this intervention is trying to tell them what to do, motivating them to reestablish their control of the situation. By using threats, fear, and a paternalistic tone to persuade teens to adopt a responsible behavior this intervention just positions itself to provoke rebellion in those that are most at risk.
Failure to Overcome Teens’ Invincibility

‘Every 15 Minutes’ acknowledges that teens understand the dangers of drinking and driving, yet most believe it will never happen to them (3). In light of this knowledge, the program was designed to show teens they are not invincible (3). In terms of social science theories, teens believing they are invincible would be called optimistic bias, illusion of control, or restraint bias. Combating teens’ optimistic bias and illusion of control seems like an effective approach to address this public health problem; however, ‘Every 15 Minutes’ fails to do so.

Optimistic bias is the phenomenon that people tend to underestimate the risk of something bad happening to them and overestimate the risk of something good happening to them (15). People tend to underestimate the probability that bad things will happen to them even when they understand or overestimate the risk that bad things will happen to other people (15). For instance, 72% of drivers do not believe it is very likely that they will get caught drinking and driving and students have been shown to think their risk of developing a drinking problem is much lower than that of other students (15-16). Under the principles of optimistic bias, even if teens fully understood or overestimated the risks associated with drinking and driving, they would underestimate their own personal risk. According to Professor Siegel, optimistic bias tends to be highest in teenagers and when trying to overcome optimistic bias, telling stories about individuals is much more impactful than delivering public health messages via statistics. ‘Every 15 Minutes’ attempts to deliver the anti-drunk driving message through a story involving peers; however, this story is only a dramatization. The intervention takes the theatrics too far with fake blood, a grim reaper, and students playing dead, so it seems like a cheesy television show rather than a realistic situation. The fact that the events of the intervention are staged limits the believability and detracts from the effectiveness in overcoming the optimistic bias of the teen audience.

Illusion of control is the idea that people have an unrealistic sense of the extent to which they can control an event or the events that happen to them (17). Illusion of control and restraint bias are essentially one in the same, with restraint bias being the idea that people overestimate their ability to control their behavior, particularly as it relates to temptation (18). Applying these principles to the problem of teenage drinking and driving would imply teens overestimate their ability to control whether or not they would drink and drive in general or be involved in a drunk driving accident. In simple terms, these overestimations account for a sense of invincibility. In studies exploring temptation control under a hot versus cold state, individuals tend to overestimate their impulse control when in a cold state and be more realistic of their abilities when in a hot state (18). Since ‘Every 15 Minutes’ is delivered in the cold state (i.e. teens are sober), teenagers will tend to overestimate their ability to say no to driving after drinking or getting in a car with someone who has been drinking. Interventions delivered in the cold state are less effective and without effectively addressing how to handle the hot state, the impact of the program is limited by its delivery.

Conclusion
‘Every 15 Minutes’ is potentially an effective intervention for anti-drunk driving. The message is delivered in a story format, largely by peers, and relies more on appealing to emotions than persuasion via statistics and facts. The intervention’s website claims participants are satisfied with the program, but does this satisfaction translate into behavior changes? Unfortunately it does not. Research has shown this intervention changes teens’ attitudes for the short term, but not their behavior (19).
The failure of this program can be partially attributed to the aggressive dramatization of the intervention. The reality is the program aims at creating a sense of hysteria in order to scare teens into changing their behavior. Teens are often hormonal and emotional, so throwing some fake blood on their friends and rushing them away in ambulance will provoke a strong emotional reaction in some teens. However, at the end of the day, teens know this two-day intervention was staged and their friends and family are safe and sound. Students can rationalize the events of the intervention are just a tall tale and go back to relying on their optimistic bias and illusion of control. Without empowering students or giving them any sense of control ‘Every 15 Minutes’ is unsuccessful in effecting behavior change amongst teens. Once the shock of experiencing the intervention wears off, it seems as though the message does as well.

Proposed Intervention
In order to reach teens, we must understand them. Through comprehending where ‘Every 15 Minutes’ fails and the application of social science theories, a more effective school-based anti-drunk driving intervention can be developed. Based on the pitfalls of ‘Every 15 Minutes,’ a more successful intervention would dispel misperceptions, minimize reactance, and combat optimistic bias and illusion of control shared by teens.

Instead of focusing on a staged, dramatization of a drunk-driving collision, the new and improved intervention could focus on sharing a true story. An individual who has lived through an alcohol-related driving experience, preferably a recent alumnus of the target high school or a neighboring school, would share their story with the high school students. The individual could be someone who was charged with a DUI or in an alcohol-related collision. They would speak to the student body about the reality of being charged with a DUI and the effect it had on their life and their friends and family. Rather than telling students what not to do, the emphasis would be on what they learned from the experience, what they lost, and how it has changed them as a person. The speech would highlight the gravity of the situation with intent to inform rather than to scare the students. The tone would be serious, but not accusatory.

The speech would be coupled with educational and interactive components. The educational component would focus on dispelling myths about teen drinking habits, empowering teens with skills on how to deal with their decisions regarding alcohol use, and providing information on local designated driver services or who to call if they ever need a ride. There would be an anonymous question and answer session where students could safely voice any questions or concerns. The intervention would get parents and the community involved much like ‘Every 15 Minutes’ does, providing an opportunity to open up dialogue with parents about drinking. The success of the anti-drunk driving campaign would be maximized through community efforts to enforce laws and a no tolerance policy on selling alcohol to minors.
Using Expectations in Another Way

The new intervention would use expectations in another way than they are used in the ‘Every 15 Minutes’ program. Rather than representing the program under a negative, exaggerated statistic, the program would flip the statistics around. Focus would be placed on dispelling misperceptions related to teen alcohol use and drinking and driving, using social norms theory to impact teen behavior. The speaker would emphasize that they are the exception not the norm and encourage students not to share in their mistake. The program would highlight the positive side of teen trends, such as the fact that the majority of teens do not drink—a recent study found that almost 60% of teens surveyed did not have a drink within the last month (1). An even greater majority, almost 83%, of people age 12-20 are not binge drinkers (20). In 2009, 90% of teens had never driven a car or vehicle after they had been drinking and 72% of teens had never ridden in a car with a driver that had been drinking (21). Drawing attention to the good decisions teens make establishes positive rather than negative expectations.

As discussed early, expectations and perceived social norms are a powerful indicator of behavior. In particular, there have been many studies on how norms influence drinking amongst adolescents and how norms can be used to reduce alcohol consumption (9-11). Correcting misperceptions has been shown to reduce problematic behavior and encourage healthy behavior (10). Most students already believe their peers drink more than they actually do and perceive their peers to be more permissive in their drinking attitudes than they actually are (11). The expectations delivered by ‘Every 15 Minutes’ only add to the misperceptions already held by students. Setting the story straight on teens’ actual attitudes and behaviors as they relate to drinking and driving will help to correct these misperceptions. Empowered with the facts, teens can feel more comfortable abstaining from drinking, reducing their drinking, or voicing their opinion against drinking and driving.
Changing Words to Minimize Reactance

The new intervention will employ the principles of psychological reactance to increase acceptance of the message and effect change in teen behavior. ‘Every 15 Minutes’ focuses on pointing out teens’ bad decisions and telling them what not to do, the new intervention will remove the accusatory tone and focus on alternative options. Instead of a ‘just abstain from the behavior’ message, the new program will have a ‘be in control message’—reminding teens they are the one’s with the power. The speaker will incorporate messages such as “We know some of you will choose to drink. If you are going to drink, arrange a safe ride home. Figure your ride out before you start drinking. Have a cab’s number in your cell phone.” These messages are more neutral in tone and leave the option up to the student, making them feel in control and thus minimizing reactance. In preparation of the intervention, the school can send home flyers to parents encouraging parents to let their children know they can always call them for a ride, no questions asked. Of course not all parents will feel comfortable with this, but for those that are, it is important their teens know they have this option.

Research has shown the persuasiveness of anti-drinking campaigns is largely dependent on the level of reactance they create (22). Reactance is minimized when more gentle, subtle language is used and when someone familiar delivers a message (12,14). ‘Every 15 Minutes’ attempts to reduce psychological reactance by involving students in the intervention program. The new intervention will go a step further, using someone familiar and toning down the paternalistic message. Students will be able to relate to the speaker because they are close in age and from the same area, creating a sense of familiarity. Removing the graphic visualizations from the intervention and using positive statistics helps to reduce the threat-to-health aspect seen in ‘Every 15 Minutes.’ By giving teens freedom to choose from options, making them feel in control, and minimizing the perceived threats, the message is more likely to be accepted by a broader audience (12-14).

The Power of a True Story
‘Every 15 Minutes’ acknowledges that there is a sense of optimistic bias and illusion of control in teens, but solely relies on theatrics and fear to overcome these obstacles. In the proposed intervention, the speaker will share their story without any of the hysterics of ‘Every 15 Minutes,’ making the message more genuine and believable. Students can dismiss ‘Every 15 Minutes’ because it is fake, the raw honesty of an individual who has actually lived through a DUI arrest or alcohol-related collision is something students cannot deny. Students will walk away feeling moved by the personal story, but not scared by fake blood and mangled cars. People can understand probabilities and even overestimate them but still not grasp their own risk—telling stories about individuals will be a lot more impactful than probabilities (15).

The most realistic approach to combating illusion of control and restraint bias is empowering teens so the illusion is removed and they are in fact in control. Interventions delivered during the hot state tend to be more impactful because people are more realistic about the level of control they have over a given situation (18). This could be difficult to accomplish because this public health issue involves underage drinking and it would obviously be inappropriate to have teens drink before the intervention. However, the goggles that simulate vision when intoxicated could be used to illustrate to teens what their coordination and perception is like when they have been drinking. By empowering teens with information, whether it is the reality on teen drinking trends or what their options are when they find themselves in a situation involving alcohol, knowledge is power. The new intervention would remove the theatrics of ‘Every 15 Minutes’ and inform teens about the less dire consequences of a DUI such as the embarrassment of telling friends you do not have a drivers license, the nuisance of not being able to drive yourself anywhere, and the negative impact it has on your ability to get a job. These consequences that affect one’s independence and social life are more relatable and relevant to teens than killing a friend or going to jail, which just seem too farfetched for most teens to fully comprehend. Illusion of control and optimistic bias are difficult to overcome, but the new intervention aims to combat these tendencies by leaving teens with a more realistic grasp on the situation.

Conclusion
Whether a life is lost every 15 minutes or every 48 minutes, the point is a life is lost. The tragedy is a death from an alcohol-related collision is completely avoidable. As public health practitioners we are responsible for intervening and educating the public on this risky behavior. However, designing and implementing an effective public health intervention is no small feat. People are complex and irrational, but social science theories can help demystify the motivations, attitudes, and behaviors of individuals. Hopefully by using these theories to design and implement an anti-drunk driving intervention teens will be persuaded to maintain healthy behaviors and change unhealthy behaviors.

































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