Sunday, June 1, 2014

Let New Yorkers Drink their soda: A reflection of what went wrong during New York soda-ban debate, and an alternative proposal- Rik Ganguly

It is no secret that obesity is major problem in the US, and in many developed and developing nations across the world. According to the Centers of Disease Control and Prevention (CDC), 16.9% of youth and 34.9% of adults were obese in 2011-2012 (1). Obesity is indicated in individuals with Body Mass Index (BMI) of 30 or greater; its onset can lead to numerous risk factors including diabetes, cardiovascular diseases, and cancer (2). In an effort to address the obesity in the City of New York, Mayor Michael Bloomberg set forth a legislation called the “Proportion Cap Rule” in May 2012 to reduce the size sugar-sweetened beverages (SSB) as a means of reducing obesity rates. The term SSB encompasses a broad range of beverages, but notably includes sodas. A landmark study done by Schulze et al. of the Harvard School of Public Health found that there was indeed an association between consumption of SSB and weight gain; during the study period between 1995-1999, women who consumed one or more SSB per day weighed an adjusted 4.69 kilograms more than women who consumed less than one SSB (3).
The New York Board of Public Health, in delivering their vote in favor of the measure, noted that 58% of adults and 20% of youth were overweight or obese in New York. Furthermore, they noted the increase in the beverage sizes of SSB and the increase of caloric intake due almost entirely to increase in SSB consumption (4). The resolution sought to reduce the maximize size of SSB cups to 16 ounces, and impose a $200 violation for merchants that violate the resolution, applicable to apply to all restaurants, fast-food establishments, delis, theaters, stadiums, and food carts in (5). The resolution was invalidated by the New York Supreme Court, finding the ban to be “arbitrary and capricious,” and the measure was therefore not enacted (4).”
Dubbed as the “soda ban”, the measure was widely unpopular; 53% of New Yorkers opposed the ban (4). While the evidence is strong for an association between SSB consumption and obesity, the measure itself ignored major tenets of social and behavior sciences that explain how the public arrives at opinions regarding health, and the social forces that are involved when individuals decide upon acting on health issues. In addition, if the measure passed, the potential efficacy of the measure may have been undermined by the public’s lack of understanding of the causes of obesity.
Get Nanny Bloomberg’s Government Hands off my Drink! The impact of ignoring Psychological Reactance Theory:
Freedom of choice is thought to be one of the most sacred values that Americans hold. The implication that government, even if drawing from its most paternalistic senses, infringing upon one’s right to choose, is viewed as an unwanted intrusion reminiscent of communism and Nazism (4). In promulgating the legislation, Bloomberg became the embodiment of this fear of government intrusion. In responding to this perceived threat, and moreover a threat to limit one’s freedom of choice in the size of their sugary beverage, detractors displayed reactance; they were acting in unison against a threat to their ability to choose. As noted by Dr. David Just, a professor at Cornell University’s Dyson School of Applied Economics and Management, the psychological reactance theory plays out by manifesting itself in a manner of “rebelliousness, a determination to circumvent this policy, an attitude of ‘I’ll show them’ (6).” This “I’ll show them’ attitude lies at the crux of the applicability of reactance theory against Bloomberg’s proposed legislation.
Psychological reactance theory posits that in light of an action or proposition that seemingly forces one to accept some condition, a motivation arises in affected individuals in seeking to undo this action or proposition, thereby displaying reactance. The theory amounts to an act of defiance, as it explains the solidification of these individuals’ intent on not accepting the proposed condition. In the scenario that was experienced in lieu of the New York soda-ban proposal, a united front of business owners, politicians, advocacy groups, and the general public banded in a movement that revolved on the idea of defying a proposed limitation. Before proceeding to highlight specific instances of reactance displayed by those opposing Bloomberg’s measure, it is important to note reactance has been deduced to be an explanation of individual behaviors in other scenarios, and therefore it’s explanation in the opposition to the New York soda-ban is not unique or isolated, but rather a part of a pattern of behavior.
For instance, the City of Miami, FL enacted legislation in 1972 that prohibited the selling and purchase of phosphate-containing detergents, because these detergents would foment the growth of algae in the city’s water supply, leading to the killing of plants and suffocation of animals, as well as the production of neurotoxins (7). While the phosphate-containing detergents were effective in cleaning, other replacement chemicals with less harmful effects could be used as replacement. The legislation, in short, was not one that appeared to be overly forbidding or oppressive. However, the very fact that it forced a limitation on choice induced a sense of rebellion in Miami launderers, many of whom obtained the banned detergent (7). Reactance is seen as an explanation for the lack of efficacy of youth alcohol interventions; a study from the 1987-1988 academic year lead by researchers at Indiana University (Bloomington) and State University of New York (Potsdam) found that those who were underage were more likely to drink alcohol than those who were of legal age (10). The authors found that legislation for underage drinking was unsuccessful because “the more important or salient an eliminated freedom, the greater will be the reactance” toward the legislation, thereby increasing the prevalence of underage drinkers as compared to legal aged drinkers (10). In a more recent example, proposed gun-control legislation at the federal or state level are often met with increase in gun sales by those who feel such legislation would curb their 2nd amendment rights (8,9).
In consideration of these scenarios in which reactance theory served as a valid explanation of behavior, it is evident that opposition to Bloomberg’s legislation is in line with other instances when perceived authority and freedom was taken away. Governor Sarah Palin famously sipped a soft drink from a 7-Eleven “Big Gulp” cup during a speech to the Conservative Political Action Committee (CPAC) in defiance of the effort for government to limit how much soft drink she is allowed to consume. Governor Sarah Palin brought a 7-Eleven “Big Gulp” cup during a speech to the Conservative Political Action Committee (CPAC) in March 2013 (11). After placing the “Big Gulp” cup on the podium, the Governor quipped “Oh Bloomberg is not around, our Big Gulp is safe, we’re cool! Shoot, it’s just pop! (11)” Although meant as a joke, the presentation was a powerful demonstration of reactance theory because it showed Governor Palin’s defying authority. She sought to recuperate the rights she would have lost had she been subjected to Bloomberg’s legislation. Additionally, social media was used extensively as a platform articulate defiance of Bloomberg’s proposal. Facebook, for example, served as a venue for soda-ban detractors to gather and to plan out events protesting the legislation; many of these protests centered on the idea drinking soda that was greater than the 16 ounce limitation sought by the legislation (12).
It is clear that one of the reasons for the failure of garnering public support of the legislation can be explained by the psychological reactance theory. The penchant for individuals to defy imposed limitations, especially if those limitations are perceived to threaten one’s freedom to choose, is very real and observed in other instances of interventions that went awry to public opinion. Therefore, an intervention that seeks to curtail the obesity epidemic cannot also be seen as a measure that curtails freedom of choice, and in this regard, the soda-ban legislation was an ill-conceived proposal.
The Marriage of Framing and Agenda-setting theory is a recipe for terrible PR:
The public’s interpretation of Bloomberg’s proposal appeared to be stymied by a combination of superior framing of the issue from the side of the detractors and the impact of agenda-setting by news organizations, where agenda-setting of a poor frame allowed for the dissemination of an unfavorable position to wide swaths of the public. Whereas Bloomberg and proponents of the soda restriction developed a frame that focused on fostering a prudent public health initiative that addressed the important issue of obesity, the opponents framed the legislation as a ban or limitation of choice in beverage. By doing a simple search on Google, it appears that the media incorporated the opponents’ frame when reporting on the legislation; a search of “New York soda ban” yields over 9.5 million results and a search of “New York soda limit” is found to produce close to 7.5 million results. The words “ban” and “limit” are an extension of the frame espoused by the opponents, and play into the notion of abridgement of one’s freedom of choice, which in turn lends further credence to the relevance of reactance theory (13). Conversely, ‘milder’ search terms that do not seem as hostile to individual rights, and that may favor the proponents, such as “New York soda regulation” or “New York soda obesity”, only yield 2.3 million and 2.0 million results, respectively (13).
Agenda-setting theory is an explanation of how news reporting impacts the level of importance that individuals confer to news items or issues. It suggests that the increase in visibility and frequency of reporting correlates with an increasing importance with which the public views the news item. The news surrounding Bloomberg’s legislation was one of the top news stories for the year 2013 in the New York City area (14.) Therefore, in incorporating agenda-setting theory, it follows that the New York public would also bestow importance upon Bloomberg’s legislation as an important issue. Furthermore, elevation of the issue to the national scene by politicians ensured that the legislation was in the national news cycle, as well, and likewise also contributing US public’s perception of it as an important issue.
In conjunction with agenda-setting theory as an explanation of the public’s perception of the importance of Bloomberg’s legislation, it is important to consider the relevance of framing, which refers to the creation of a narrative surrounding the issue, and a narrative which is continuously advocated to affect perception and opinion. The elements that constitute a frame are as follows: 1) title, 2) core position, 3) metaphor, 4) catch phrases, 5) symbols/images, and 6) core values. From the opponent’s position, a frame was created based on the core values of autonomy, civil liberty and freedom of choice, predicated on the core position that Bloomberg’s legislation was an overreach by the government in restricting choice which drew from the metaphors of “the nanny-state” and “big government”. Catch phrases of the opponents included terms such as personal choice and freedom, and the frame invoked images of Nazism and Communism (4, 12). Conversely, the frame articulated by supporters of Bloomberg’s legislation was that it was an essential public health initiative to address the obesity epidemic in New York City, and regulation of sugary drink consumption would in fact be a prudent method in addressing obesity, which without its implementation would lead to increased risk in hospitalizations and poor health. It drew from the core values of health and prevention, and likened the initiative to legislations that were passed for the good of public health, including smoking regulations. The differences in framing between the supporters and detractors is that the former constructed a narrative on the promoting of health while the latter articulated a vision of an attack to one’s inherent and cherished right to choose.
The frame promoted by the legislation’s detractors plays in well with respect to an element of news-worthiness, which is the reporting of a controversy, and especially a controversy that involves freedom of choice. On the other hand, the promotion-of-health frame peddled by the supporters does not qualify as an item that is deemed newsworthy, since heath issues in and of itself (not including unusual health issues) is simply not issues that area appealing to the public. Because the supporters’ frame was missing key elements of news-worthiness, news organizations reported on the issue from the perspective the opponents, invoking words such as “soda-ban” and “soda-limit”, as ascertained by viewing the number of results from Google’s search option (13). The elevation of Bloomberg’s legislation to being an important news topic combined with the articulation of this news from a standpoint that was favorable to the opponent’s frame in effect resulted in a public that also found the news of Bloomberg’s legislation to be important, and moreover, important from a standpoint defined by the opponents. Such impact serves to underscore the relevance of agenda-setting theory in explaining opposition to Bloomberg’s legislation, especially if viewed with consideration to the importance of framing.
Public’s lack of understanding of the link between SSB and obesity renders the Health Belief Model an ineffective tool:
One of the major motivations for New York’s Board of Public Health in adopting the Portion Cap Rule was predicated on the notion that people tend to consume whatever amount of food or beverage that is offered, without being fully aware that more food or beverage is being consumed, and furthermore, the impression of being “full” is adjusted to accommodate for this increase in amount, where being “full” may have previously meant consuming a smaller amount (5). They cited a study where “people eating soup from self-filling bowls ate 73% more, without perceiving that they had eaten more,” and by extension they implied that a similar scenario was observed related to the consumption of SSB where “people drink more without…experiencing a difference in “fullness” or “thirst (5).” By passing the resolution to reduce SSB portion sizes, the evident intent of the Board of Public Health was to inform the public of the issue of portion sizes and the consumption of extra calories as a result of increase portion sizes. In essence, the Board of Public Health sought to inspire the public to be more attuned to the mind-set of “fullness” when consuming SSB. The Board of Public Health therefore seemingly relied in part on the Health Belief Model as way to rein in obesity; however, dependence on this model would be problematic due to a lack of perceived susceptibility to obesity from SSB.
The Health Belief Model (HBM) is a theory that suggests that individual health decisions is tantamount to a balancing act, where one considers the perceived benefits of the intervention and weighs it against the perceived costs. It follows that when the perceived benefits outweigh the perceived costs, the individual will make a decision in favor of the perceived benefit. In the event that an individual is being asked to support or partake in a program to combat a disease or health problem, the HBM offers that the individual would need to fulfill the following criteria: 1) belief in a perceived susceptibility to that disease or problem, 2) belief in the severity of the disease or problem, 3) belief in the benefits of taking part in the program, 4) belief in being able to overcome any barriers that may reduce the effectiveness with how the program combats the disease or problem, 5) respond to ‘cues to action’ that motive one to partake in the program as means to combat the disease or problem, and finally 6) self-efficacy, or confidence in the ability to take part in the program (15). It is apparent that by passing the resolution, the New York City Board of Public Health sought to invoke the HBM to highlight the problem of obesity, and to bring the public into a more pro-active state of addressing obesity amongst the city’s residents.
Although the public believes that obesity is a significant health issue and is aware of poor health prognosis for obese individuals, the public does not seem to attribute SSB to obesity; instead, they attribute the primary causation of obesity to spending too much time watching TV or using the computer, followed by eating fast foods and ignorance of weight management (16). Therefore, the public’s perceived susceptibility is undermined by the fact that they do not believe SSB has a major causative impact on obesity. It can be implied that many individuals would find the resolution to be ineffective, thus undermining the premise of the measure as a means to address obesity.
A way forward- a proposal for an alternative measure to address obesity:
In evaluating the failure of the Proportion Cap Rule, and its subsequent failure in garnering public approval, an approach to obesity cannot be seen as restricting and a measure that limits one’s freedom to choose. As noted, positioning a measure as a restriction leads to reactance, and ultimately exacerbates the effort to reduce obesity by motivating behavior that is opposite to the desired behavior. The articulation of measure must be clearly planned out and framed as a narrative that does not inspire hostility; Bloomberg’s push was framed around the narrative of health, which failed to compete with the narrative of freedom of choice that was publicized by opponents. The inferior narrative, compounded with the news media’s agenda-setting ability, led to the proliferation of a disliked narrative into the domain of public importance, which further prevented support of the measure. Finally, the public simply was not sold on the idea that SSB was an important factor that contributed to obesity; and the reliance of the HBM to affect a reduced consumption of SSB was weakened by the failure of the supporters to articulate the potential for susceptibility to obesity by means of SSB consumption. Another underpinning of Bloomberg’s initiative was a failure to appreciate the larger dynamics that impacts opinion and decisions regarding health, including environmental, personal influences, and observing the action of others. A proposed intervention, therefore, should capitalize on the opportunity to impact these domains. One intervention alternative intervention that has been considered is increasing the taxes of SSB; however, changing tax policy has the chance to draw the same public ire as restriction on SSB cup size, and its impact in reducing SSB consumption is dubious (11).
In light of these considerations, a specific intervention that may be potentially suitable and efficacious is proposed here: a city-wide initiative that promotes the consumption of water. Water is healthy, convenient, and ubiquitous. Moreover, water can be utilized as substitute for SSB consumption. Residents will not be told what size of SSB that they are allowed to drink; rather, water is being promoted in manner that increases its consumption and in turn decreases the need for SSB consumption, thereby reducing the prospect of reactance by the public. The initiative, in its very basic sense, would adopt an “all-of-the-above” approach in promoting the consumption of water in at least the following ways: 1) to make water more readily available to city residents, including (but not limited to), allocating revenue to supplying free water to poorer residents, eliminating all other beverage options except for bottled water in all New York City government properties including City Hall, schools, civic buildings, etc., providing incentives for businesses to sell water by providing tax credits to businesses who are able to sell a certain amount of water in a one year period; 2) creating videos and advertisements of regular city residents and celebrities who praise water consumption and discuss the impact and importance of water consumption and spreading these videos through social media outlets; 3) prompting minor changes in the curriculum for public early childhood institutions to include lessons about water and its importance to the body. The proposal does run the chance of being mocked for its simplicity, however, it will not be perceived as hostile in the way the Proportion Cap Rule was viewed.
Learning to love water, as explained by Social Cognitive Theory:
The crux of the water initiative is that it focuses on a positive message and seeks to impart this message in manner that proliferates amongst the domains that impact the individual’s behavior. The effort to improve access and availability of water, especially to poorer residents, allows for fewer barriers that may restrict water consumption in some populations. Advertisements promoting water consumption combined with educational reforms at the early childhood stage serve as a means to normalize water as the primary beverage for consumption. The water initiative, in short, invokes tenets of Social Cognitive Theory, to achieve its end of reducing SSB consumption and in turn, reducing obesity.
Social Cognitive Theory (SCT) is a model that posits that the three main factors that influence change in behavior are (amongst other factors that are mentioned later): 1) self-efficacy, 2) goals, and 3) outcome expectancies (15, pp 19-21). The increased availability of water under the proposed measure ensure that the condition of self-efficacy is met because residents would find improved access to water in many facets of the cityscape, from governmental offices to stores and merchants who use the lure of tax credits to improve sales of water. The message of the importance of water consumption through city-sponsored advertising would serve to reorient one’s goal, where the goal of the individual wouldn’t necessarily depend on individual’s aim to reduce obesity, but to achieve a goal of drinking more water (and therefore, less SSB), which in effect would theoretically lead to obesity reduction. It is important to note that the goal could in fact be to reduce obesity, especially if this goal is impacted by advertising. The key takeaway, therefore, is that the goal does not need to be aligned with obesity reduction in order for the obesity reduction to occur.  Outcome expectancies would be modified to reflect an expectation of healthier living due to increased intake of water in place of SSB; even though the goal of water consumption may not be reduce obesity, the act of drinking water in place of SSB would linked to reduced instances of obesity.
Another facet of SCT is the concept of reciprocal determinism, which explains the interaction between the individual, behavior, and the environment of that individual (15, pp 20). The water initiative impacts all three prongs of reciprocal determinism, in part by fostering and encouraging behavioral change that results in greater water consumption. The dictum that observing the experiences and behaviors of others compels the individual to adjust his or her behavior is also another tenet of SCT. The water initiative confers tremendous effort in fostering a change in the opinion of water consumption through the tools of advertising and the amending of early childhood education. The invoking of the SCT in explaining the impact of the water initiative allows for the consideration of external influences to an individuals health behavior, which differs from how the HBM was utilized in the Proportion Cap Rule.
Revisiting the frame argument and agenda-setting theory:
The rejection of Bloomberg’s initiative represents a failure in framing of the issue. The water initiative offers a start contrast in such exercise in framing; it focuses on offering choices (of water) as opposed to limiting choice, which allows for the articulation of a frame that is more palatable to the public. As mentioned, the freedom of choice is cherished American right, and being able to adopt this core position disarms opponents from employing this core position against the water initiative. Even if opponents construct a frame to the effect of the freedom to choose to be obese, the idea of having more beverage options as proposed by the water initiative would be a more pleasing concept that the freedom in choosing to be obese. Moreover, the water initiative, while being proposed as a measure against obesity, isn’t required to invoke the obesity argument in the way that restricted and bound the discussion surrounding the Proportion Cap Rule.
Armed with a less controversial frame, agenda-setting theory reasons that that the water initiative would not capture headlines with the same level of importance as Bloomberg’s initiative. Therefore, the compounded impact of a poor frame and in being a newsworthy item is a situation which can be avoided in proposing the water initiative. The proposal can be subjected to criticism and derision; the idea of promoting water above other beverages may be construed as an assault on the free market, or the idea of promoting water, something that is common and banal, but invite ridicule. However, the water initiative’s lack of restrictive proposals ensures that such attacks would not gain traction as compared to the attacks on Bloomberg’s proposal.
Selling water as a brand:
The use of advertising theory in promoting public health is not new. The Florida “truth” campaign demonstrated how focusing on the idea of rebelliousness lead to the reduction in tobacco use (18). In line with the same reasoning, the water initiative presents the opportunity for utilizing marketing tools to advertise for the consumption of water. The advertisements would ideally be creative, humorous, and emotionally-driven. It is important to note that the advertisements do not need to focus on marketing water’s health benefits or even mentioning the obesity issue; instead, the motive would be to simply ‘sell’ water. In the Florida “truth” campaign, the focus of the message was not necessarily on health issues of tobacco, but inspiring a feeling of rebellion and autonomy from the tobacco industry (18). Whereas previous anti-tobacco campaigns failed because of too much emphasis on health without an adequate focus on emotion, the “truth” campaign succeeded (18). It is in this same spirit that the water initiative can also succeed.
In conclusion:
The debacle from the Proportion Cap Rule serves as a lesson on evaluating the applicability of social and behavioral theory in promulgating public health interventions. The water initiative seeks to learn from those “lessons” by considering the lessons of relevant social and behavioral theory to promote a proposal that seeks to reduce the obesity problem in New York. Because there is evidence that reduction in SSB may lead to reduction in obesity, interventions designed to restrict SSB is prudent step-forward in tackling obesity (19).
(1) Ogden, Cynthia L. et al. Prevalence of Childhood and Adult Obesity in the United States, 2011-2012. Journal of the American Medical Association. February 26, 2014. Volume 311, Number 8. pp 806-814.

(2) World Health Organization. Health Topics: Obesity. Accessed April 26, 2014.

(3) Schluze, Mathias B., et al. Sugar-Sweetened Beverages, Weight Gain, and Incidence of Type-2 Diabetes in Young and Middle-Aged Women. Journal of the American Medical Association. 2004; 292: 927-934.

(4) Ax, Joseph. Judge Blocks New York City large-soda ban, Mayor Bloomberg vows to fight. Accessed April 25, 2014.

(5) The Portion Cap Rule. Accessed April 24, 2014.

(6) Healy, Melisssa. Proposed Soda ban likely to backfire, study finds. April 24, 2014.

(7) Iyengar, Sheena. Why the Soda Tax Makes Us Angry: Higher Prices are bad, Being Told What to do is Worse.  Accessed April 24, 2014.

(8) Miller, Emily. Obama Backfires: Gun sales in 2013 smash all Records. Accessed April 22, 2014.

(9) Associated Press. Maryland Gun-Control law Sparks record Gun sales. Accessed April 25, 2014.

(10) Engs, Ruth C and Hanson, Donald J. Reactance Theory: A Test with Collegiate Drinking. Psychological Reports. 1989, 64: 1083-1086

(11) ThinkProgress Tp [screen name].  March 16, 2013.Sarah Palin with Big Gulp. Retrieved from Accessed April 25, 2014.

(12) Facebook, Inc. Bruce Fenton [screen name]. March 11, 2013. Accessed April 28, 2014.

(13) Google, Inc. Accessed April 29, 2014.

(14) CBS New York. The Top 13 News Stories of 2013. Accessed April 25, 2014.

(15) National Cancer Institute. September 2005. Theory at a Glance: A Guide for Health Promotion Practice. 13-15.

(16) The Associated Press- NORC Center for Public Affairs Research. Obesity in the United States: Public Perceptions. Accessed April 21, 2014.

(17) Edwards, Ryan D. Preventative Medicine. Commentary: Soda taxes, obesity and the shifty behavior of consumers. 2011: 52; 417-418.

(18) Hicks, Jeffrey J. The Strategy Behind Florida’s “Truth” Campaign. Tobacco Control. 2001; 10: pp 3-5.

(19) Hu, F.B. Resolved: There is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related disease. Obesity Reviews. 2013: 14; 606-619.

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