Thursday, May 22, 2014

Five a Day - Diana Vo

The 5 A Day Program campaign was introduced in 1991 by the National Cancer Institute and the Produce for Better Health Foundation to spread awareness and motivate people to eat the suggested five to nine servings of fruits and vegetables every day. In 2011, the CDC became head of the 5 A Day Program in the United States so that the Center could provide various resources including leadership, educational, and technical assistance to the 5 A Day directors. To promote their campaign, the CDC offered a 5 A Day Works! publication that was a collection of fifty-four success stories from 5 A Day directors. (1) The campaign’s overall message was that a diet that includes a vast variety of fruits and vegetables can help people stay healthy as well as reduce their risk for chronic diseases. However, there are a number of flaws regarding this campaign.
Critique Argument 1 – Health Belief Model Lacks
The Health Belief Model was a model created in the 1950s by social psychologists Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels.  Research was conducted to determine what motivated people’s health behavior.  The model stated that behavior is an outcome of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Perceived susceptibility refers to the person’s perception of whether they are at risk of developing the health problem.  The Health Belief Model predicts that if a person perceives that they are susceptible then they will engage in behaviors that will reduce their risk of developing that health problem. Perceived severity refers to a person’s perception of how severe the health problem is. If a person views the health problem as serious then they will engage in behaviors to reduce its severity. Perceived benefits refer to whether the person believes there will be benefits of taking action. If a person believes that taking action will reduce their susceptibility and the seriousness of a health problem then he or she will likely engage in that behavior. Perceived barriers refer to an individual’s obstacles to perform a behavior. If there are barriers that inhibit a behavior change then the perceived benefits must outweigh the perceived obstacles in order to perform a behavior. Cues to action is the component of the Health Belief Model that states a cue is needed in order to begin a behavior change. Lastly, self-efficacy refers to an individual’s belief that she can successfully make that behavior change.  (2) Behind every public health intervention is a theory, and behind every theory are assumptions. The number one assumption behind the Health Belief Model is that people make rational decisions by doing an internal cost-benefit analysis. The Health Belief Model projects that people’s decisions are simply a balancing act. They are balancing the perceived benefits of behaving versus the perceived costs of behaving.  
Since the 5 A day campaign was based on the Health Belief Model, it assumed that individuals would eat healthily as long as they wanted to. However, the Health Belief Model simply focuses on the individual and does not account for the many external barriers that influence health behaviors such as social and environmental factors. Social and environmental factors include location, time, money, and transportation. Furthermore, the Health Belief Model assumes that everyone has equal access to information that allows for rational decision-making. (3) The 5 A Day campaign did not consider geographic and economic costs and factors that are often out of a person’s reach such as access to fresh, healthy, attractive, and inexpensive produce. Linda Thomas, Assistant Professor of Nursing, argues that the Health Belief Model is a westernized conception of human behavior.  It dehumanizes people and blames the victims. Often times, the easiest solution is to blame the victim if he or she is not behaving ideally. The model presumes that the fault lies with the individual and that he or she is ignorant, which leads to judgmental views versus understanding the circumstances. (4) This illustrates how the 5 A Day campaign should not have been based on the Health Belief Model. Because people might not be eating give fruits and vegetables a day, they are often deemed as ignorant rather than constrained by uncontrollable factors.  Since the Health Belief Model is based entirely on the individual level, focusing on perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy, it should not have been used in the 5 A Day campaign to change people’s behaviors.
Critique Argument 2 – Framing It the Wrong Way
The traditional public health paradigm is to analyze the product that people should want, then use intuition to frame and sell that product to appeal to the desire for health in consumers.  A frame is a way an issue is presented or discussed in the news and media. It is intended to encompass the arguments, images, and appeals of the particular issue, situation, or intervention at hand. (5) Because a frame is a way of packaging an issue so that it conveys a particular meaning, it can be quite powerful. (6) A study, conducted by Claudia Menashe and Michael Siegel, analyzed newspaper coverage of tobacco issues in the United States from 1985 to 1996. For many decades, public health officials have provided evidence that tobacco use can be hazardous. However, tobacco use still remains legal, accessible, and acceptable in society. Public health officials have not been able to battle the influence of the tobacco industry, because of how tobacco use was framed as a public health problem.  Public health officials used framing theory in the wrong way. Previous frames have argued that tobacco kills smokers and nonsmokers, and it was society’s duty to eliminate these avoidable deaths. (6) However, this method is flawed because health is not a strong core value in the minds of the American people. Furthermore, tobacco addiction is often framed as the fault of the individuals. Rarely, is the addiction ever blamed on the tobacco industry themselves.  Tobacco companies are actually the ones manufacturing and marketing these products to all. Thus, framing it on the individual level may not be the most effective way to change behaviors.
In their article titled “Framing Theory,” Dennis Chong and James Druckman discuss framing effects. These occur when (often small) changes in the demonstration of an issue can produce (sometimes large) changes of public discourse. For example, when asked whether respondents would be for or against allowing a hate group to hold a political rally, 85% of respondents answered in favor if the question was prefaced with, “Given the importance of free speech,” while only 45% were for the rally when the question was prefaced with, “Given the risk of violence.” (7) This demonstrates how alternatives phrasings of simple issues can significantly change public opinion regarding an issue.
In the 5 A Day program, campaigners mistakenly framed and assumed that health is a very strong core value among people. They promoted the various health benefits that can result from filling one’s plate with plenty of fruits and vegetables. However, the general population does not tend to value health as highly as public health practitioners do. The campaign strove to promote the idea that fruits and vegetables are essential to one’s health. However, the 5 A Day campaign lacked an identity that people wanted to ascribe to. Contrary to popular belief, people often do not value health until they no longer have it. Most people could not imagine themselves committing to a fives fruits and vegetables on a daily basis. Thus to them, health is a lower core value than love, autonomy, security, justice, equality, etc.  Framing health as a core value is not necessarily wrong, but it is limiting and ineffective.  If done correctly, framing is an effective way of changing people’s behaviors. However, the 5 A Day campaign framed its message inefficiently.
Critique Argument 3 – Psychological Reactance
By telling people that they should eat five fruits and vegetables a day, the 5 A Day campaign would potentially elicit psychological reactance. Psychological reactance theory states that when people’s freedom is threatened, they experience reactance and have to take action to restore that freedom immediately. (8) The way that people restore their freedom is by committing the forbidden acts. An example of this was shown in the study by Sharon Brehm, “Physical Barriers and Psychological Reactance: 2-year-olds Responses to Threats to freedom.” In this study, Brown exposed 2-year-old boys and girls to 1 of 3 different situations involving a physical barrier. The first barrier was a large barrier with identical free-standing objects behind the barrier. The second barrier was also a large barrier with dissimilar objects behind it. Lastly, the last barrier was a small barrier with dissimilar objects. The results of the experiment showed that boys preferred the object that was behind the large barrier with dissimilar objects (i.e. the second barrier). On the other hand, the girls chose the objects behind the non-barricaded, more accessible object, i.e. the third barrier. (9)  The boys went for the object that they could not easily get to, while the girls tended to go towards the toy that was available. This implies that at two years old, boys had already developed psychological reactance. Even though the boys knew that they could not get the toy, the felt compelled to acquire it because of its inaccessibility. Thus, the toy’s non-reachability became attractive for the boys, who wanted it even more.  
Another example that showcases psychological reactance was the study by Richard Driscoll called “Parental Interference and Romantic Love: the Romeo and Juliet effect.” This study examined a series of unmarried couples and measured the degree of parental interference in their relationships. Proctors administered questionnaires to one hundred and forty couples to test the hypotheses that (a) feelings of love are highly correlated with trust and acceptance as the relationships develop over time and (b) parental interference in a love relationship deepens the feelings of romantic love within the couple. The study found that parental interference was the strongest predictor of marriage and continuing relationships because of the motivating effects of frustration and reactance. The more the parents interfered, the more likely the couples stayed together. (10)  This contradicts what most people would actually think. Because the parents interfered with the couples, it caused reactance, and thus the couples wanted to be together even more, i.e. get their freedom.
As presented by these studies, the implication of reactance theory is that people do not like being told what to do. That is precisely why the 5 A Day program was flawed. The campaigners were telling people to eat five fruits and vegetables a day, which elicited a reactance, thus leading to the exact opposite behavior. Therefore, one must avoid reactance to create an effective program.
Articulation of Proposed Intervention
The 5 A Day program was flawed because it was derived from the health belief model, framed health as a highly important core value, and elicited psychological reactance. The campaign can be adjusted and changed to address the current flaws in order to promote its ultimate message of getting people to eat more fruits and vegetables. Firstly, since most people already know the health benefits of eating fruits and vegetables, the campaign should understand that people’s health decisions are often constrained. The directors should attempt to implement subsidies for fresh produce and accessible supermarkets so fresh produce can be more affordable, available, and appealing. Secondly, the 5 A Day campaign should not focus on framing its issue around health but rather on the core values of autonomy and freedom, so that people can aspire to lead a good life for themselves, their families, and loved ones. The campaign should brand an identity and a promise to people that if they eat fruits and vegetables, they will feel empowered. Lastly, in order to reduce psychological reactance, the 5 A Day campaign should utilize a messenger who is similar to the target audience. The messenger could range from young chefs in the kitchen to respected celebrities promoting healthy living.
Defense of Intervention Section 1 – Providing Access
Instead of the health belief model, the 5 A Day campaign should not be based on understanding the reason people behave in certain ways, but it should provide mechanisms to accomplish the campaign’s desired outcome. The 5 A Day campaign should not just tell people that they should eat five fruits and vegetables a day, because people often already know the health benefits. The 5 A Day campaign ought to view the issue from a micro-environmental stance, by promoting different outlets that will help people make these healthy decisions. The campaigners should focus on the price, access, and quality of produce, which as a result will make food more affordable, available, and appealing. This can be done by implementing subsidies for fresh produce (which would lower the price for consumers) or providing low-income families greater access to supermarkets and healthy quality food, rather than convenience stores and fast food chains.
The study titled, “Neighborhood Socioeconomic Status and Fruit and Vegetable Intake among Whites, Blacks, and Mexican Americans in the United States,” conducted by Tamara Dubowitz, examined associations between healthy food intake and neighborhood socioeconomic statuses, thus determining whether neighborhood socioeconomic status explains the racial differences regarding intake of fruits and vegetables. The study found that neighborhood socioeconomic status was positively associated with fruit and vegetable intake. Therefore, this positive association demonstrates that unlike people’s own desires to eat healthily, the social environment of neighborhoods largely dictates population health and nutrition for white, blacks, and Hispanics in the United States. (11) Thus, the effective way to promote healthy eating is to control for these influential factors.
An experiment during Michael Siegel’s SB721 class demonstrated the disparity between the food people eat and the location of their shopping. Students were asked to purchase various fruits and vegetables in the two neighborhoods of Boston: the South End and Roxbury. Students who were sent to Roxbury found bruised apples from the convenience store and shreds of lettuce from Subway. On the other hand, students who were sent to the South End were able to find shiny apples and a whole head of lettuce. This experiment represented the residential disparity of quality and access to food. Low nutritional value food was placed in poor neighborhoods while high nutritional value food was placed in wealthy neighborhoods, even though they were located right next to each other.  This experiment demonstrated how one’s environment is a strong predictor of how healthy he or she will eat.
Both these examples show the persistence and enormity of the socioeconomic and racial-ethnic disparities in health statuses in the United States. Lack of behavior change is not always due to absence of desire but external factors that dictate the change. People often do not have the money to move to a wealthier neighborhood in order to gain access to fresh produce. Therefore, the 5 A Day program can combat this disparity by not telling people to eat fruits and vegetables, but rather providing the means for the healthy behavior.  Regardless of the peoples’ presently built environments, the campaign should make the food resources available, whether by implementing subsidies for fresh produce or providing low-income families greater access to supermarkets and healthy quality food.
Defense of Intervention Section 2 – The Power of a Frame and Marketing
Since the 5 A Day frames its campaign around the core value of health, issues can be re-framed in a different way by using marketing techniques. As discussed in class, the marketing paradigm uses research to uncover people’s needs and wants, create and package the product so that it fulfills those needs and wants, and appeal to more basic human core values. Marketing companies create a psychographic profile of the target population so that they know what appeals to the audience, like the color of the packaging. The companies attempt to understand who their audience is so that they can cater and fit their brand to the various personalities. The marketing team must fashion, frame, and package their product to appeal to people’s aspirations, dreams, needs, and wants. Furthermore, marketing teams must understand the most important core values of their target audience, whether it is love, money, autonomy, security, justice, or health. That is what the public health practitioners did regarding tobacco use. They framed the tobacco companies as manipulating nicotine levels, deceiving the public, and perpetrating tobacco addiction to children. Rather than focusing the tobacco issue as a public health problem, new frames focused on the tobacco industry’s deceptive or illegal behavior. (6) These frames appealed to the core values of justice, dignity, and fairness.
Every element of a campaign including the name, logo, colors, message, presentation, and execution has to be especially consistent with the core value that the campaign is trying to appeal to.  Consequently, the campaign has to align with the needs and aspirations of the target population. Thus, the goal of the 5 A Day campaign should not command people to eat more fruits and vegetables; it must be framed in a way to inspire them to eat more fruits and vegetables. That frame can inspire individuals to lead a good life for themselves, their families, and loved ones.  The 5 A Day campaign should market autonomy and freedom rather than health as the campaign’s core values.
Furthermore, every single public health intervention should be branded into an identity that people will associate with the product and that is coherent throughout the campaign. A branded message is strategic because it provides a promise. For example, by eating more fruits and vegetables, people will have the freedom and autonomy to live their lives versus to be held back by health issues. A campaign that followed this technique was the 84 campaign. The 84 campaign is a statewide movement of youth fighting tobacco in the Commonwealth of Massachusetts.  The 84 campaign was successful because it did not promote health as a reason to not smoke but rather focused on the individual feeling important. They promoted the idea that one can be a part of a movement, the 84% of Massachusetts youth who did not smoke when the campaign started. (12) Once children are labeled and adopt that identity, it becomes a part of who they are.  This campaign does not belittle youth by telling them what to do. Rather, children are joining a movement and thus being labeled in a positive way.  By using framing and marketing techniques, the 5 A Day campaign can embody an identity that provides people with autonomy and freedom. As a result, people will more likely adopt that identity and its desired behaviors.
In addition to these marketing techniques, an important factor is not to challenge existing beliefs but reinforce them. Most public health campaigns are trying to change people’s point of view. The campaign should not try to change value and beliefs; they must try to reaffirm pre-existing beliefs. It needs to show that the campaign’s mission is to promote the existing values, because an attempt to change people’s beliefs actually elicits reactance and reaffirms their beliefs. Hence, the 5 A Day campaign should endorse people’s beliefs that if they eat fruits and vegetables, they will feel empowered to do whatever they desire.
Defense of Intervention Section 3 - Ways to prevent psychological reactance
The 5 A Day campaign is flawed because it elicits reactance. The way to avoid reactance is to ensure that whoever is portraying the message in the advertisements are people who are the most similar to the target audience. In the study conducted by Paul Silvia “Deflecting reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance,” he tested the theory of whether interpersonal similarity could possibly lessen reactance by increasing compliance and decreasing reactance. (13)  In this study, he had four elements of similarity. One communicator shared the participant’s same birthday, first name, gender, and year in school. The second communicator did not share any factors with the participants. And the third communicator was the control in which people did not know any information about the person. The study found that in situations of similarity, reactance was greatly reduced. The high-similarity groups perceived the communicator as less coercive. When similarity was low, the communicator caused reactance because he seemed threatening to the subjects’ freedoms. Thus, the source of the similarity was irrelevant; the fact that the subjects and the coordinators shared some similarities greatly reduced reactance. This experiment implies that the nature of the messenger is crucial. The more similar the messenger is to the audience, the less reactance there will be. Therefore, if the intervention is targeting youth, then youth should be included in the advertisements.  The exception is the use of celebrities, since they are viewed highly by the general youth.
Since the 5 A Day campaign had elicited reactance because it told people what to do, then it should reduce reactance by having a messenger that is similar to its target audience. If members of the campaign are targeting the youth, then similar children should be used so that the youth audience can empathize and not elicit reactance, whether it is a home video of children in the kitchen cooking with their parents or an advertisement with their favorite cartoons. Likewise, if the campaign is aiming to influence adults, then other adults that share a commonality should be used in the advertisements as well. This could either be a family member or someone who is honored and well respected in the community. Whatever the outlet is, the messenger should be similar to the target audience.
            This critique of the 5 A Day program is an example of a public health intervention that failed to incorporate social and behavioral sciences could result in program failure. Social and behavioral theories should be applied to the intervention in order to create innovative and effective public health intervention programs. Rather than individual health behavior models, group level models should be used in order to communicate an important health message to the public.  Rather than basing the 5 A Day program on the Health Belief Model, the campaign should use marketing and framing theory to reduce psychological reactance, promote autonomy and freedom, and provide access to the necessary means of living a healthy life.   

1.     Centers for Disease Control and Prevention. 5 A Day Works! Atlanta: U.S. Department of Health and Human Services; 2005.
2.     Rosenstock IM: Historical origins of the health belief model, Health Education Monographs 2:328-335, 1974.
3.     Edberg, Mark Cameron. "Individual Health Behavior Theories (Chapter 4)."Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.
4.     Thomas, Linda W. "A Critical Feminist Perspective of the Health Belief Model: Implications for Nursing Theory, Research, Practice, and Education."Journal of Professional Nursing 11.4 (1995): 246-52.
5.     Certain Trumpet Program. Framing Memo: The Affirmative Action Debate. Washington, DC: Advocacy Institute, September 1996.
6.     Menashe, Claudia L., and Michael Siegel. "The Power of a Frame: An Analysis of Newspaper Coverage of Tobacco Issues-United States, 1985-1996."Journal of Health Communication 3.4 (1998): 307-25.
7.     Chong, Dennis, and James N. Druckman. "Framing Theory." Annual Review of Political Science 10.1 (2007): 103-26. Print.
8.     Brehm, Jack W. 1966. A Theory of Psychological Reactance. New York: Academic Press.
9.     Brehm, Sharon S., and Marsha Weinraub. "Physical Barriers and Psychological Reactance: 2-yr-olds' Responses to Threats to Freedom." Journal of Personality and Social Psychology 35.11 (1977): 830-36.
10.  Driscoll, Richard, Keith E. Davis, and Milton E. Lipetz. "Parental Interference and Romantic Love: The Romeo and Juliet Effect." Journal of Personality and Social Psychology 24.1 (1972): 1-10.
11.  Dubowitz, Tamara. "Neighborhood Socioeconomic Status and Fruit and Vegetable Intake among Whites, Blacks, and Mexican Americans in the United States." American Journal of Clinical Nutrition 87.6 (2008): 1883-891.
12.  "Home." The 84. N.p., n.d. Web. 20 Apr. 2014.
13.  Silvia, Paul J. "Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance." Basic and Applied Social Psychology 27.3 (2005): 277-84.

Monday, May 19, 2014

Ensuring the Success of Our Youth: A Critique of Our Current Approaches- Divya Mehta

        Underage alcohol use is one of the most pervasive problems affecting our youth. The period of adolescence is one filled with discovery, the development of one’s identity and the launching pad for many of the decisions that will affect their future lives. The issue of alcohol use in this population is not a novel one, but rather a problem that has plagued many generations of vulnerable youth. In 2009, the CDC reported that 48% of the deaths in youths between 15-19 were due to accidental injuries(1). This figure also includes 5,000 deaths a year attributed to alcohol consumption such as motor vehicle accidents, alcohol poisoning, or homicide. These numbers have been increasing rapidly with each passing year and there have been numerous campaigns targeting these youth in an effort to decrease their alcohol consumption.  
      In a time during which various forms of media are a continual part of one’s day, there’s a multitude of different messages being sent to these youth and many are struggling to determine the best course of action for their health and lives. Whether it’s through advertisements for specific brands or the inclusion of teenage drinking in popular TV shows, the message often targeting the youth is that alcohol consumption is a natural part of growing up and represents the transition from being a naive kid to becoming an adult. There has been no shortage of public health campaigns trying to stem this movement such as “Say no to Drugs” or “D.A.R.E” (2,3). However, none of these programs has been effective in altering the level of alcohol consumption in adolescents in the long term due to their inability to make messages that appeal to their target audience.
          One of the most recent campaigns is “My Instead”, which uses videos to reach out to teens about the benefits of abstaining from alcohol consumption and choosing another activity to fill their time(5,). Their main promotional video focuses on a young group of teens, approximately middle-school age. The first scene outlines the group dynamics in which one of the teens is clearly the bully and is trying to convince one of the other boys in the group to steal a bottle of liquor from his parent’s party they are about to have that evening. He brags about being the only member of the group who has tried alcohol and puts pressure on the other boy to provide them alcohol so they can all try it like him. The boy who is pressured spends the remainder of the afternoon planning the best way to steal the bottle with another female member of the group who he is romantically interested in. After obtaining the bottle, the entire group meets up and prepares to open the bottle. The video then allows the viewer to watch three potential endings to this scenario. The first involves the pressured boy spilling the alcohol on the bully and refusing to drink it, which gains the approval of the female character. The second option involves a family member coming to look for the alcohol. He offers them different options for why drinking would be bad for them and the dangerous effects it could have.  The last scenario involves the boy giving into the pressure and ultimately throwing up on the girl which causes all of the friends to leave his house.
Ineffective Use of Social Learning Theory
     I believe that this video and campaign were attempting to employ the Social-Behavioral model of Social Learning theory to present its message. The main premise of this theory is that the primary form of learning occurs through interactions with peers and other members of a person’s life (4). These interactions are believed to be the basis for the development and continuation of new behaviors.  However, in order to encourage the individuals to adopt the behavior, the model should be similar and relatable to that person.  I believe that the use of a group of children as opposed to an individual in this scenario was effective because it did allow for the viewer to observe how group dynamics impacted the decisions made, which is a common part of social interactions. However, one of the reasons this video failed was the age group used is far younger than the target audience for these videos.  Studies have shown that adolescent drinking can commence during middle school, but media campaigns are far more ineffective than school or community-based campaigns(6,7). Studies have shown that targeting middle-school aged children is effective in the short term, but this behavior change isn’t maintained as they get older(6, 9,10).In addition to the effectiveness of alcohol interventions, the majority of adolescents have their first experience with alcohol in high school (8,11)  The target audience for alcohol campaigns is 15-19, which also corresponds with a period when their emotional and social skills are continually evolving(12). In addition, adolescents are eager to accentuate this emotional development by striving to appear as mature as possible. Showing them a video of younger children stealing alcohol would be completely unbelievable and would lead to them mocking it as opposed to using it as a learning tool.
     Another issue is that they only focus on the motives of the boys within the group for drinking, but don’t provide any motivation for the girl in the group except that she’s going along with what her crush is doing. Alcohol consumption is a problem for both genders, and this video primarily focuses on the males’ behavior. The focus on this type of behavior only reinforces the misconceptions that surround drinking in young females. The most recent reports from the Partnership for Drug Free America showed that teenage females who report drinking by the age of 18 has increased dramatically by 15% during the past 15 years and is now the same as teenage male drinking rates(12). One of the contributors to this increase is the availability of fruity and sugary drinks which encourage binge drinking among this population. However, the primary contributor is that females are increasingly turning to alcohol use to self-medicate in response to increasing stresses at school or home. Thus, by introducing a character whose primary motivation is mimicking her romantic interest, this campaign is failing to create a model that is similar and relatable to the target population.
Resistance to Authority Figures
     The use of scare tactics by authority figures has been a strategy used by public health officials to combat the rise in alcohol use in teenagers, but has demonstrated little success. Adolescents are generally very resistant to following the advice of their parents and often strive to behave in a way that defies them. This type of behavior is described by the Psychological Reactance theory, in which people react strongly when they perceive that their personal freedoms or ideals are being infringed upon(13). For teenagers, the ideal that they treasure the most is the freedom to make their own decisions and assert their independence. In this video, the only time that the detrimental effects of alcohol use is mentioned is by the boy’s uncle who is looking for the missing bottle of Tequila. While using the uncle to spread this knowledge slightly reduces the resistance the teens might have to his message, he still represents a source of authority which the teenagers are unlikely to follow. The act of stealing this bottle of alcohol is the first rebellious action and allows him to assert a position of power amongst his group of friends. For teenagers watching this video, it is likely that this feeling of power is something that they would relate to. However, the advice given by the uncle would likely be very ineffective in changing their behavior because it is in direct opposition to the actions that they are taking that make them feel more confident and powerful. In addition to inducing resistance in adolescents, scare tactics often induce more anxiety and stress. Many studies have suggested that this increased stress actually causes the teenagers to drink more to assuage these feelings as opposed to stopping.
Failure to Utilize Marketing Theory
     One of the primary reasons why many public health campaigns fail in reaching their target audiences is because they don’t employ some of the same techniques that the large alcohol companies do. The primary theory that the alcohol industry uses is Marketing Theory(14). It relies on appealing to the core values and desires of the consumers, and then structuring their product in such a way that it appears to fulfil these aspirations. As mentioned previously, the general goals that all teenagers generally have are to gain freedom from authority figures and to have control over their lives. However, the only theme of gaining freedom and control in this commercial is linked to how the boy feels when he steals the bottle of alcohol. Within his group, he is generally considered the odd one out and is bullied for not doing all the same activities as the cooler kids within his group. At the beginning of the video when they are first discussing drinking, the two popular kids within the group belittle the boy and his crush for being the only ones to not try alcohol. By providing the group with alcohol at the end of the video, he establishes himself within the group as the leader who has the power. Thus, instead of using their desire for power and control to promote abstaining from alcohol, this video is actually more effective in demonstrating that drinking will allow you to achieve your goals.  
     Another way in which this video fails to appeal to the desires of the target population is its length. Due to the rapid development and integration of social media into the lives of teenagers, they have become reliant on short bits of media to provide them information and entertainment. Between Facebook and Twitter, most of the messages they are able to broadcast are limited to less than 200 characters. The target audience for this message is not interested in long, drawn out videos, but rather something short that they can absorb quickly. The main body of the video lasts for 5 minutes and each of the alternate ending videos require clicking on a different link and last up to a minute. It is highly unrealistic that adolescents in the target audience would actively watch this video, given its’ content on alcohol use. This video is also only available on YouTube and has not been marketed onto any other form of social media that would be more readily accessible.
Proposed Modifications to Model
     While I commend this campaign for employing the use of group dynamics in this promotional video, I don’t believe they were successful in providing models that their target audience can relate to. One of the ways in which they could resolve this issue would be to produce informational material that is age-specific. There is a wide age range that is being targeted by these messages, which does make it an issue to create material that can effectively appeal to all of the different age levels. Since the premise of this campaign is to show the target audience what they could be doing instead of drinking, a potential idea would be to make promotional materials that contrast the activities that the teenagers could be engaging in at each different age rang to their lives while drinking. This structuring by age would allow the target audience to not only better identify with the models presented, but also observe the progression of their behavior and lives if they choose to drink at this young age. I believe that these modifications would better suit the target audience and make the campaign more successful in reducing alcohol consumption.
     In addition to adjusting the age demographics for the target audience, I believe a significant improvement would be tailoring their campaign to address the differences that gender has on the rates of adolescent drinking. As mentioned earlier, alcohol consumption in teenage girls is now equal to that of boys, but most of the campaigns only focus on the boy’s motivations for drinking. Females are primarily drinking as a way to deal with the intense pressures they are feeling emotionally and physically. One way to combat this might be show promotional videos in which the females are exposed to stress but are able to use other healthy alternatives for stress relief such as enrolling in yoga, outdoor activities, or joining the arts. In addition to encouraging teenage girls to find an activity that they enjoy, it would also be helpful to emphasize that using alcohol to combat emotional problems and stress is only a temporary solution, but that there are other options out there that will provide them more relief in a more positive way.  Another comparison of a life with and without these activities I believe would provide female teenagers with a model for how to deal with some of their issues in a healthy and productive way.
 Alternatives to Scare Tactics
          There have been numerous campaigns at the high school and college levels that have tried to employ different techniques other than scare tactics. A potential model for this program is the “truth” campaign, an anti-smoking campaign. One of the most effective aspects of that campaign was their way of presenting the facts which are still just as chilling, but in such a way that was accessible to the viewer. Whether it was laying out body bags or singing about how “5 million deaths must be a typo”, the creators of this campaign were able to present the audience with the same type of facts that are thought provoking(15). Many studies have shown that this campaign was extremely successful in providing more information to students while decreasing the smoking rates in adolescents who viewed the commercials (15). While deaths due to alcohol aren’t on the same scale as those due to smoking, the fact that 5,000 teenagers die each year from alcohol-related incidents would likely be a shocking fact to teenage drinkers. Inundating teenagers with facts isn’t necessarily effective, but providing them with more information about the consequences on a larger scale might resonate with them. A potential ad campaign for teenage drinking might involve a hundred teens standing in a crowd and being partitioned off to represent the different proportions of teens that die each year from various causes. As I mentioned earlier, 48% of teenage deaths are due to accidental injuries and a percentage of that population are those injuries due to alcohol use. By representing these statistics with actual people, it might be able to get the message across to the audience that accidents and life events happen to all of us, but those that involve alcohol use are avoidable and only you can make that choice to make yourself safer. This way of structuring this information I believe would provide information to these teenagers to reinforce the idea that they aren’t invincible and the choices they make do have consequences.
Altering Appeal of Target Message
One potential solution is to employ the use of labeling theory. The basic premise of this theory is that a person’s behavior is influenced by the way that they are perceived by outsiders and they will conform their actions to fit this “label” they are given(16). Cornell University developed the “Smart Woman” anti-drinking campaign on their campus using this theory. Their primary focus wasn’t necessarily on stopping drinking on their campus, but rather encouraging them to make smart decisions when drinking so that they maintained their safety. They appealed to the “label” that smart woman make good decisions and that every woman on their campus is a “smart woman”. Their intent is that the women on the campus would adopt this label and act in a safe way while drinking. Some of the posters for this campaign showed images of a “smart woman’s purse” before going to a party which included bringing along money for a cab fare at the end of the night and a condom just in case something happened. They also launched a separate campaign for men that included posters with the slogan, “Smart Men Pre-Game with Food”.  Follow-up surveys on their campus displayed a significant decrease in the number of alcohol related incidents on campus involving women after the conclusion of this campaign (17). I believe that the primary benefit of using labeling theory in alcohol prevention is that it appeals to the positive traits within people and builds them up instead of focusing on their flaws that lead to them making bad decisions. One way to apply a concept like this at the high school level could be to appeal to teenagers through the different activities that they are involved in. For example, if they wanted to focus on a teenager that is really involved in the music world, they could show the everyday items that they need to achieve their goals of becoming a professional performer. This could include the sheet music that they learn from, a guitar pick, and a bottle of water among other items. The advertisement could label the water as the key to their success because it hydrates their vocal chords and makes them better singers. The bottom of the advertisement could mention that a successful musician has these items in their toolkit and focus on how alcohol isn’t included. This advertisement would use labeling theory but presenting them with the label of successful musician that they would want to live up to. By presenting some of the items that they need to achieve this success, they are building up the image that if they combine their talents with these tools, that they have the ability to achieve their life dreams which don’t involve alcohol use.    
     While there have been numerous studies that have examined the use of television and radio in public health campaigns, there have been few papers that have examined the effectiveness of using social media to disseminate the knowledge. I believe that in order to reach teenagers in an effective way, we need to alter the way in which we are providing them information. One way to craft these messages would be to employ the use of advertising theory. When many advertising firms are developing advertisements, they do copious amounts of research to determine the primary characteristics of the demographic that they are targeting. I believe that we should use this same level of examination to determine the best way to target adolescents.  Twitter and Facebook are two of the primary forms of social media used by teenagers and if we could create content that could be used on these platforms, I believe that we would to provide the message in an applicable way. One of the most popular items that are shared on these sites are “memes” which are pictures or small movies with writing associated them that portray usually a humorous or thoughtful message. A particular meme that was circulating social media was one that focused on a particular activity or profession and provided the different ways in which people perceived that same activity. For example,  a meme that focused on teachers portrayed them thinking that their job saves the world whereas the children view them as slave masters that rule their life. I believe that making a meme like this about alcohol use would be one potential way of showing adolescents the different perceptions their peers and parents have of drinking. By putting this message in a form of media that they are comfortable with seeing, I think this would an effective way of reaching them and providing them with the information that they need to make decisions about drinking.
     The “My-Instead” Campaign is one that attempts to provide their target audience with the knowledge about the effect that alcohol use can have one an adolescent’s life. While they do employ certain techniques such as the use of groups to display the importance of group dynamics in these types of decisions, there are three main flaws in their delivery of their message. They most importantly fail to employ Social Learning Theory to create a model that other adolescents can relate to when actively choosing not to drink and fail to address the differences in motivations for drinking between genders. This campaign also tries to use scare tactics and don’t market this information in a way that appeals to their target audience. My first solution was to create advertisements or videos that focus on alcohol consumption at different ages and genders to provide better models that the entire target audience can relate to. I also believe that using labeling theory will enable students to feel empowered in making decisions that will lead them to their eventual life goal without using alcohol along the way. Lastly, using forms of social media would be a more effective way to provide this information in a context that is easily accessible to the target audience and mirrors the content they use in other parts of their lives. Adolescent drinking is a serious problem that needs to be addressed in order to ensure that the future generations of adolescents are able to achieve their full potential without being hindered by poor life decisions.

1.      National Institute on Alcohol Abuse and Alcoholism (NIAAA). Report on Underage Drinking. Washington, DC. US Department of Health and Human Services, 2013.
2.     Seitz, C.M., Wyrick, D., Orsini, M.M, Milroy, J.J, Fearnow-Kenney, M. Coverage of Adolescent Substance Use Prevention in State Frameworks for Health Education: 10 Year Follow up. J Sch Health. 2013; 1:53-60
3.     Clayton, R.R., Aattarello, A.M, Johnstone, B.M. The Effectiveness of Drug Abuse Resistance Education (project DARE): 5-year follow-up results. Prev Med. 1996; 3:307-18
4.     Bandura A.  Social Learning Theory. New York: General Learning Press, 1977
5.     New Mexico Department of Transportation.My-Instead Campaign. 2013. <>
6.     Clark, DB, Gordon, AJ, Ettaro, LR, Owens, JM, Moss, HB. Screening and Brief Intervention for Underage Drinkers. Mayo Clin Proc. 2010; 4:380-391
7.      Verdurmen, JEE, Koning, IM, Vollebergh, AM, Regina, JJM, Rutger, CME. Risk moderation of a parent and student preventive alcohol intervention by adolescent and family factors: A cluster randomized trial. Preventive Medicine. 2014; 60:88-94
8.     Windle, M., Zucker, RA. Reducing Underage and Young Adult Drinking: How to Address Critical Drinking Problems During this Developmental Period. Alcohol Research and Health. 2010; 33:29-43
9.     Verdurmen, JEE, Koning, IM, Vollebergh, AM, Regina, JJM, Rutger, CME. Long-Term Effects of a Parent and Student Intervention on Alcohol Use in Adolescents: A Cluster Randomized Trial. Am J Prev Med 2011;40(5):541–547
10.  American Medical Association. The Legal Drinking Age and Underage Drinking
11.   in the United States. Arch Pediatr Adolesc Med. 2009 163: 598-600
12.   Partnership for a Drug Free America. Adolescent Drinking Survey Results, 2009.
13.   Jack. V Brehm. A Theory of Psychological Resistance. 1966
14.   Murray, Keith B. A test of services marketing theory: consumer information acquisition activities. The Journal of Marketing.1991; 10-25.
15.   Niederdeppe, J, Farrelly, MC. Confirming “Truth”: More Evidence of a Successful Tobacco Countermarketing Campaign in Florida. American Journal of Public Health, 2004; 94
16.   Mead, G. H. 1934. Mind, Self, and Society. Chicago: University of Chicago Press, 1934
17.   Cornell University. Smart Woman Campaign. 2006

“The Real Cost” Campaign to Reduce Youth Smoking – Satvinder Kaur Dhaliwal

“The Real Cost” is the Food and Drug Administration’s (FDA) first tobacco prevention campaign targeting youth between 12 and 17 years of age who are open to smoking or are already experimenting with cigarettes (1). Through this campaign, the FDA aims to reduce smoking initiation rates among youth and reduce the number of youth experimenting with cigarettes (1). The campaign was launched on February 11, 2014 and will continue for at least one year (1). The FDA describes the campaign as consisting of messages that “educate at-risk youth about the harmful effects of tobacco use with the goal of reducing initiation rates among youth” (1). Campaign advertisements will be delivered through multiple media outlets, including radio, internet, and television. The campaign also includes digital games to attract youth to learn about the consequences of tobacco use.
            The main messages of the campaign are health consequences and loss of control leading to addiction. Multiple media sources to relay messages are expected to surround youth with campaign messages. “The Real Cost” is expected to reach 9 million youth, which is 90% of the target audience, 60 times per year (1). Campaign messages are based on research findings indicating that “The Real Cost” television advertisements are engaging and do not have unintended counterproductive messages (1). However, analyzing the campaign with social science theories reveals that several flaws could cause the campaign to be ineffective.
Critique 1: Hierarchy of Needs
            “The Real Cost” is trying to strike deeply held adolescent values of independence and youthfulness, but the man of the messages are based on health as a core value. For example, one of “The Real Cost” video ads shows a young person purchasing cigarettes at a roadside convenience store. When the teen attempts to pay for the cigarettes with money, the cashier replies, “You need a little more.” In order to fulfill the cost of the cigarettes, the young woman rips a piece of skin off of her face and pays the cashier (2). Thereby, the ad is based on the core value of health and sends the message that if you smoke, you will pay with your healthy, youthful skin.
            The FDA’s attempt to convince youth with a health argument contradicts Maslow’s hierarchy of needs, which suggests that human needs are arranged in a hierarchy of power. Higher level needs will only be realized if the most basic needs are realized. Physiological needs are at the lowest level of Maslow’s hierarchy, thus physiological needs have the greatest influence upon an individual’s choices. Health is not at the lowest level and is not among the most influential needs of a human. Therefore, messages that aim to change health behavior must strike a more important human need than health (3).
            Maslow’s hierarchy of needs should be an integral aspect in the FDA’s campaign because the campaign targets “at-risk” youth, who may have more important needs than health. The FDA indicates, “Campaign messages are intended to make the target audience acutely aware of the risk from every cigarette by highlighting consequences that youth are concerned about, such as loss of control due to addiction and health effects…” (1). Thus, the campaign assumes that young people care about self-control and health. Although self-control is important to youth, health may not be a top priority (4). Health is even less of a priority among the group identified by the FDA as “at-risk”. One aspect of “The Real Cost” campaign includes a fictional character, Pete, who is facing unstable social and economic situations in his home and at school. The campaign explains that Pete is living in suburban or rural areas with unmarried parents. Therefore, Pete’s primary concerns are regarding family insecurity and home insecurity. Based on Maslow’s hierarchy of needs, health is not a top priority for Pete, so awareness about health consequences will not dissuade Pete from smoking. Therefore, “The Real Cost” has created a fictional character who may not realistically be convinced by the campaign’s arguments.
            Additionally, many of the campaign posters, available on the FDA’s website are based on health as the core value. The themes of the four posters are chemicals, stunted lung growth, aging skin, and oral health (5). The most glaring message on these ads is about health, while smaller print strikes at youth independence. The following statement, “We give it to you straight. You can make your own decisions. Know the real cost of tobacco use.” appears at the bottom of each poster, in relatively small font. Therefore, youth are most likely to read the message about health consequences of smoking, which does not address an important core value.
            Although nicotine, which is found in cigarettes, is known to accelerate the aging process, one study found that smokers do not pay attention to the detrimental affects of smoking on the body (6). Furthermore, Urbańska et al also found that smokers’ decision to smoke is not influenced by knowledge of the fact that skin damaged by nicotine use can only be improved by cessation of nicotine use (6). Therefore, core value of health, and specifically wrinkle-free skin, does not hold great value for adolescents. Furthermore, an individual in the targeted age group is not very likely to have wrinkled skin. Therefore, the FDA’s effort to influence youth decisions around smoking is based on a value, health, which is relatively insignificant to the target audience.

Critique 2: Illusion of Control
            While some advertisements developed by the FDA use a stronger core value of independence, other flaws inhibit these ads from engaging youth. In an attempt to portray the negative lifestyle of addiction, two television ads created by the FDA use a four-inch tall bully as a metaphor for a cigarette. The bully speaks in an aggressive tone and the advertisement provides several examples of how cigarettes control adolescents’ actions – the cigarette bully literally drags a teenager out of a school hallway, forcing him to smoke on demand; the cigarette bully demands that a teenager “fork over” money upon demand, presumably to buy cigarettes; and the cigarette bully forces a group of teenagers to pause a movie and then drags one teenager outside to smoke (7). The core value in both cigarette bully advertisements is self-control and the message is that smoking cigarettes leads to an addiction that takes away adolescents’ ability to control how they spend their time.
            When comparing this advertisement to research studies on adolescent perceptions of smoking, it seems that the cigarette bully advertisement completely contradicts how youth perceive cigarette use. One study found that among low-income African American and European American 14 to 16 year olds, the primary reasons for smoking are that smoking is a coping mechanism, smoking is associated with social acceptance, and smoking is encouraged by environmental influences (8). Adolescents actually view smoking as a stress reliever, whereas “The Real Cost” cigarette bully portrays cigarette smoking as a source of stress and lack of self-control.
            The illusion of control theory can be used to explain why youth, who are considering smoking, prefer cigarette smoking compared to non-smoking. Illusion of control theory suggests that individuals are more likely to predict success for themselves when they feel like they are in control, compared to when they feel like they are not in control (9). Therefore, adolescents are likely to feel that smoking allows them to control their level of stress more than non-smokers. In comparison, “The Real Cost” cigarette bully ad shows individuals that the cigarette is in control of their behavior and stress. Based on the theory of illusion of control, successful campaigns give people a sense of ownership, whereas “The Real Cost” shows individuals losing control of their time. This portrayal in the advertisement challenges, rather than reinforces, deeply held adolescent values of control and ownership.
            Finally, psychological reactance theory explains that when an individual thinks he or she is losing control, he or she performs the forbidden action in order to restore lost or threatened control (10). Therefore, youth are more likely to smoke after watching the cigarette bully advertisement in order to reassure themselves of the self-control that appears to be threatened by smoking.
Critique 3: Flaws in Advertising
            It is useful to analyze “The Real Cost” campaign in comparison to the truth campaign because both campaigns are targeted to reduce smoking initiation rates and to reduce smoking among youth who are already experimenting with cigarettes. The “truth” campaign, which was a successful youth-targeted anti-smoking campaign in Florida, employed seven aspects of advertising – secure funding, youth involvement in campaign development, youth marketing, use of an acceptable tone, anti-manipulation strategy, branding, and focusing the campaign on a single problem (4). However, in comparison to the “truth” campaign, “The Real Cost” violates several aspects of advertising that were found to be beneficial in “truth”. For example, Hicks explains that “truth” was developed with respect to youth preferences and youth feedback on the creative process (4). Thus, developers of “truth” learned that a successful campaign would have to “surprise and lead” the target audience rather than present images that the audience is expecting to see (4). Additionally, youth have a strong distaste toward anti-tobacco campaigns that pass judgment on tobacco users, and youth prefer to receive the facts and make their own decisions rather than receive messages telling them what they should not do.
            Although “The Real Cost” was developed based on evidence-based practices and research that identified the most promising messages, it is too early in the campaign to analyze evaluation findings (1). Therefore, the advertising theory and findings from the “truth” campaign will be used to evaluate the potential of “The Real Cost” campaign. The FDA’s campaign presents images that youth expect to see and, much to youth distaste, the campaign tells youth what to do. “The Real Cost” essentially tells youth not try cigarettes and stop experimental smoking, but the campaign fails to provide a socially accepted alternative behavior. One of the valuable finding in the “truth” campaign research was that youth do not engage with messages that tell them what to do (4). Furthermore, “The Real Cost” is further disadvantaged by presenting images that youth are familiar with, such as wrinkled skin, tooth decay, gum disease, and consequences of damaged lungs. Youth are well aware of the consequences of smoking, so more information about health consequences will neither engage the target audience nor inspire change in behavior (4).
            In addition to lack of engagement, “The Real Cost” does not provide an equally valuable alternative to smoking. As reported by Hicks, youth perceive smoking as a form of rebellion, and because rebellion and independence are important youth values, these must be replaced when a form of rebellion or independence is taken away. “Truth” was successful in reducing youth smoking rates because it led youth in a rebellion against tobacco companies rather than repeat the harmful consequences of smoking as evidence to why youth should not smoke (4). Essentially, “truth” replaced rebellion expressed through smoking by creating a movement of rebellion against the control tobacco companies attempt to have on young peoples’ decisions to smoke.
            In contrast, “The Real Cost” tells youth not to smoke in every single advertisement. Thereby, removing youth rebellion and freedom to smoke, but the campaign fails to replace rebellion and freedom. Although, campaign posters and postcards use the tagline “We give it to you straight. You can make your own decisions. Know The Real Cost of tobacco use”, other messages by the campaign try to encourage teens to stop smoking. For example, radio ads about health consequences end with the following statement, “So even when you’re not paying… you’re paying.” This can be interpreted as a way of telling teens that they should stop smoking if they truly want to stop paying for cigarettes. However, “The Real Cost” campaign ads do not replace the rebellion that teens take part in when they smoke. Thus, the campaign doesn’t present an alternative behavior for teens to engage in.
            Finally, “The Real Cost” fails to present strong advertisements. Advertising theory suggests that strong advertisements should have three components – a strong promise, vivid support, and strong core values to support the promise (4). Most of “The Real Cost” campaign’s television ads lack a strong promise and strong support. One television ad, called Alison, shows a girl speaking about the negative addictive impacts of smoking. She speaks about smoking as if she is speaking about an ex-boyfriend, referring to the smoking addiction as ‘he’ and never using the words cigarette(s) or smoking. She describes smoking as a controlling and needy boyfriend by making statements like “everywhere I went, he had to follow”, “Outside, now!”, and “bossy, so bossy”. Alison also reminds teens that she initially overlooked the facts that she had learned about the addictive side effects of smoking by stating, “First I didn’t take him seriously. I had heard the stories, but I thought they were really overblown. But overtime, he became, like, really annoying.” The promise in this ad is that if teens smoke, their lives and decisions will be controlled by an addiction, and the support provided in this ad is a young girl talking about her addiction in comparison to a needy boyfriend in an attempt to relate to an unpleasant situation teens may have experienced. The support used in the Alison ad is very weak because it lacks vividness, such as images to visualize the unpleasant situation of living with an addiction or the desirable affects of living without an addiction. Although the core value freedom has potential to be strong, the promise and support used to advocate for freedom limit the core value’s potential. Finally, the advertisements fail to tell a story. Each campaign advertisement presents health or addictive consequences of smoking in relation to something that teens have witnessed, experienced, of heard about. Bullying and an unpleasant relationship are metaphors used in “The Real Cost” advertisements. Although teens may be able to relate to these metaphors, the ads are not executed in a way that will be accepted by teens.
Articulation of Proposed Intervention
            In order for a national campaign to be successful, it is important to remedy the flaws identified above so that the campaign will engage youth rather than turn them away. Some changes are needed in order for “The Real Cost” to be effective. In this section, I propose an intervention based on social science theories and research findings.
            “Break Free from the 3” will be an anti-smoking campaign that targets youth as a group rather than at the individual level. It will educate youth on the power that three tobacco companies have on young people’s decision to smoke (11). There will be emphasis on the idea that so few companies are able to control all of America’s youth. The campaign will deliver messages through television advertisements, posters, and educational rallies at sporting events and schools. Television advertisements will show youth coming together in large groups and breaking free of the barriers to freedom imposed on them by three tobacco companies. At the beginning of the advertisement, youth will appear helpless, unambitious, and living in a gloomy world with little potential. The world outside will be bright, colorful, and beaming with opportunity. The visual will include youth wrapped inside a cigarette roll, small groups will start spreading ideas about exploring the world outside, and finally youth will break through the cigarette skin preventing them from knowing their full potential in the world. Youth in the television ads will be diverse in all aspects of social life.
            Poster ads will show images of youth uniting to break free of the tobacco industry’s chains on their freedom and ability to choose a lifestyle. Rallies at high schools will serve as a place to excite youth about the campaign and educate youth on the strong influence that three tobacco companies have been able to achieve. Rallies will be different from classroom settings, with free gifts to remind students of their commitment to independence. A critical aspect of every rally will be participants’ chance to literally break through a giant cigarette butt. Each rally will feature a giant cigarette butt umbrella that hangs over the rally, labeled with facts about the three tobacco companies, ways the companies have managed to target specific groups of youth, and how companies continue to influence youth decisions over several years. At the end of each rally, youth will have a chance to unite, which will involve peer encouragement to increase the size of the group, and push through the umbrella. By doing so, youth will have joined a national pact to break free of the tobacco influence and remain independent.
Strong Core Values
            A strong anti-smoking intervention should be based on a core value that is important to youth. As explained by Hicks, youth value independence and rebellion (4). Therefore, an anti-smoking campaign needs to encourage youth to take control of their freedom and demand independence. “Break Free from the 3” will educate youth on the systematic method of control enforced on youth by just three tobacco companies. Although prevention of smoking will improve health status, the core values used in “Break Free” are independence and freedom, which are identified as most important values to youth (4). Additionally, “Break Free” television advertisements are based on the core value of freedom and satisfy Maslow’s hierarchy of needs theory. In these advertisements, youth will be depicted as unable to breath inside the cigarette world. Thus, there is need for a physiological need, which are the most important needs based on Maslow’s hierarchy of needs (3).
Youth Control and Social Expectations
            All “Break Free” advertisements and rallies will show young people uniting to achieve independence. Based on social expectations theory, an intervention must change social norms associated with a behavior in order to change the behavior itself (12). As explained by Hicks, one reason youth decide to smoke is social acceptance. Therefore, a large-scale campaign that encourages youth to join a group seeking independence can change the norms around social acceptance.
            Furthermore, the emphasis on three major tobacco companies is to empower youth. Showing youth that there are many more young people than there are powerful tobacco companies gives them ownership of the campaign. Thereby, illusion of control theory is successfully applied to give youth ownership of something positive and powerful. While the final goal of the campaign is to change youth attitudes about smoking so that smoking is not perceived as a positive or socially acceptable practice, the campaign never tells youth that they should not smoke. Instead, the campaign will creatively educate youth on tobacco companies’ tactics targeted to entrap youth while they are young. However, youth will be empowered throughout the entire campaign so not to portray that youth are losing ownership of the rebellion that encourages smoking, as suggested by Hicks (4). Although indirectly, youth are being encouraged not to smoke, the smoking rebellion is replaced with a rebellion against the three main tobacco companies. Therefore, Hicks’s explanation of replacing rebellion is also fulfilled, as it was during the “truth” campaign (4). Consequently, replacing rebellion is a way of replacing the freedom that youth lose when they are told not to smoke. Therefore, “Break Free from the 3” prevents psychological reactance in youth.
Effective Advertising
            Finally, “Break Free from the 3” will be executed with application of advertisement theory. Therefore, campaign advertisements are based on a strong core value with a strong promise that is presented with vivid support. For example, the television advertisement described above is based on the core value of freedom, which is highly valued by youth as described by Hicks and discussed above (4). “Break Free from the 3” campaign’s television advertisement promises youth that if youth unite against three major tobacco companies, they will be able to achieve the freedom to make decisions that allow them to achieve their full potential. Support for the promise is provided through vivid images. In the television advertisement, when youth are trapped inside the cigarette, the setting will be gloomy and individuals will be somber. Youth inside the cigarette world will look very similar to each other, showing that there is little freedom to dress or behave as one chooses. Youth will depict a sense of being trapped inside the cigarette. However, the world outside the cigarette will be lively, colorful, and filled with youth who choose how they dress and construct their personalities. Thus, the world outside the cigarette gives youth ownership of expression. Essentially, the support in television advertisements will tell a story of youth empowering themselves to achieve independence, and viewers will be able to follow the journey to independence. Thereby, “Break Free from the 3” television advertisements will successfully fulfill all three aspects of advertising theory in order to engage the target youth audience.
            Based on theories of social science and findings from successful anti-smoking campaigns, it is apparent that successful campaigns need to be conscious of youth needs. Campaigns to change youth behavior should also be framed in a manner that will engage youth and encourage participation. Therefore, “Break Free from the 3” presents a youth focused and youth targeted initiative that empowers youth through ownership of the campaign. “Break Free from the 3” is differs from “The Real Cost” by giving youth ownership of their own independence, which in itself is empowering. Finally, campaigns to change youth behavior must refrain from telling youth how to change behavior. Instead it is critical to frame messages in a way that leads youth to change behavior on their own will.

  1. FDA. The Real Cost Campaign [Internet]. [cited 2014 Apr 23]. Available from:
  2. The Real Cost Commercial: “Your Skin” [Internet]. 2014 [cited 2014 Apr 23]. Available from:
  3. Maslow A. A theory of human motivation. Available from:
  4. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tob Control. 2001;10(1):3–5.
  5. FDA. The Real Cost Campaign - The Real Cost: Free Materials [Internet]. [cited 2014 Apr 28]. Available from:
  6. Urbańska M, Ratajczak L, Witkowska-Nagiewicz A. [Analysis of knowledge about tobacco smoking influence on skin condition]. Przegla̧d Lek. 2012;69(10):1055–9.
  7. The Real Cost Commercial: “Bully” [Internet]. 2014 [cited 2014 Apr 24]. Available from:
  8. Scales MB, Monahan JL, Rhodes N, Roskos-Ewoldsen D, Johnson-Turbes A. Adolescents’ Perceptions of Smoking and Stress Reduction. Health Educ Behav. 2009 Aug 1;36(4):746–58.
  9. Langer EJ. The illusion of control. J Pers Soc Psychol. 1975;32(2):311–28.
  10. Brehm JW. A Theory of Psychological Reactance. Organization Change: A Comprehensive Reader [Internet]. Jossey-Bass; 1966. p. 377–90. Available from:
  11. CDC. Smoking and Tobacco Use; Fact Sheet; Economic Facts About U.S. Tobacco Production and Use [Internet]. Smoking and Tobacco Use. [cited 2014 May 1]. Available from:
  12. DeFleur M, Ball-Rokeach S. Socialization and Theories of Indirect Influence. Theories of Mass Communication. 5th Edition. White Plains, NY: Longman, Inc.; 1989. p. 202–27.