Public Health initiatives and interventions utilize campaigns to invoke change in health-related behavior in a population. Interventions aim to change by behavior through various methods, such as increasing awareness, changing attitudes and motivations, increasing physical or interpersonal skills, changing perceptions, influencing social norms, changing structural factors or, or influencing the accessibility of health services (1). Campaigns to control drug cause have, historically, “…emphasized an approach based on instilling fear about a substance through dramatized description and images of the consequences of use couple with a notion of treating people with harsh punishments out-of-step with the harm caused by the drug” (2). The Meth Project is an example of a drug-use reduction campaign that exemplifies the models used historically. More specifically, the Meth Project is a large-scale campaign currently used in eight states that aims to reduce use of methamphetamines through “…public service messaging, public policy, and community outreach” (3). The Meth Project grew from the Montana Meth Project, a statewide prevention program, established in 2005 by Thomas M. Siebel, founder and chief executive officer of Siebel Systems. The Meth Project has expanded its reach and has programs in Mr. Siebel’s home state of Illinois, Arizona, Colorado, Georgia, Hawaii, Idaho, Montana, and Wyoming (4). The Meth Project uses a “…research-based marketing campaign, community action programs, and an in-school lesson” to raise awareness about the risk of methamphetamine use (3).
To name a few of the consequences, long-term abuse of Methamphetamines is associated with severe tooth decay, and skin sores, symptoms of psychosis, neurotoxicity and other neurobiological effect, increased risk in stroke, and other damaging effects on the central nervous system (5). Because of its highly addictive properties, effects on the central nervous system, and potential for abuse, Methamphetamines is classified as a Schedule II stimulant that can only be obtained legally with a non-refillable prescription in low doses (5). Its potential for abuse stems its short-term effects, such as “increased activity and talkativeness, decreased appetite, and a pleasure sense of well-being or euphoria” (5). In 2011, according to the Drug Abuse Warning Network, methamphetamine was the fourth most mentioned illicit drug in hospital emergency departments (5). The 2012 National Survey on Drug Use and Health determined that 0.2% of persons 12 years or older, or 440,000, were current users of methamphetamines (6). It is important to note that while methamphetamine use is not a common occurrence in most of the United Sates, there are a few areas with higher rates (2). The burden of disease is not only health-related issues but also many negative social outcomes, including “…high levels of unprotected sex; problems with work, family, personal relationships, and the legal system; emergency room admissions; and death from heart attack and stroke” (7). While 47% of county sheriffs reported meth as their primary problem (8), between the years of 1999 and 2004, methamphetamine use rates remained around 0.2-o.3 % among Americans (9). The steady rate of use of meth brings to question the effectiveness of the meth project.
Critique 1—Ineffective Use of Fear Appeal Theory
As mentioned earlier, fear is a prevalent motivational tool in many public health campaigns. The Meth Project is no exception. The Meth Project primary method of communicating information is the use of advertisements, many of which are graphic in nature (10). The Meth Project uses advertisements in television, on radio, in print, on billboards, and online. The advertisements include graphic imagery with “…illustration of the decay of users’ bodies, young girls selling their bodies to older men for meth, violent criminal behavior committed by meth-hungry teens, and groups of meth users leaving their friends to die” (11). Radio advertisements include personal stories of teens with experiences with meth. Television commercials, as well, portrays meth users as poor decision makers, violent, unhygienic, and exploitive (10). These images, I argue, instill fear. The advertisements convey to the viewer that using meth will result in scary, immoral situations. The violent images convey to the user that meth is a substance that he or she should be afraid to use “Not. Even. Once” (10). Using Fear as an appeal for behavioral change is not always effective. Fear Appeal Theory is explained by three components—fear, threat, and perceived efficacy (12). “Fear is defined as negatively valenced emotion, accompanied by a high level of arousal” (13). Threat is explained as an external factor that creates a perception that a negative situation may arise (12). The third component of fear appeal is efficacy—the idea that a recommended action will reduce the threat. Using fear as a tactic is most effective when there are both a high level of threat and a high level of efficacy (12). In the drive-reduction model of fear, the assumption is “(a) that when fear is sufficiently intense, it motivates instrumental responding, and (b) that any cognitive or behavioral response that reduces a negative state such as fear is inherently reinforcing (12).The Meth Project’s graphic imagery instills fear, the efficacy, however, is called into question. The Meth Project relies on the drive reduction model of fear and assumes that showing the consequences of meth will scare viewers enough to not use meth (12). Surveys conducted by the Montana Meth Project found that “the percentage of teens that saw “no risk “ from using meth once or twice rose from 3 percent before the campaign’s introduction to 8 percent 6 months later. The same increase was seen in the percentage that saw “no risk” to regular meth use” after being exposed to the campaign (14). Rather than increasing the perception of meth as a high-risk substance, the campaign backfired and may have diminished the perceived threat of meth use. Additionally, there is no clear element of efficacy. That is, there campaign lacks a strong recommendation that viewers can take besides “Not. Even. Once” or “Ask MethProject.org” (3). For the use of fear appeal theory to be more effective, a stronger action item or recommendation, or element of perceived efficacy is suggested.
Critique 2—the Health Belief Model
Fear Appeal Theory contains within it some elements of the Health Belief Model. The intervention approaches in the Meth Project are based on many of the constructs of the Health Belief Model. The Health Belief Model has four elements—perceived susceptibility, perceived severity, perceived benefits of an action, and perceived barriers to taking that action (15). Briefly, perceived susceptibility refers to the cognizance of risk for a health problem (15). In the context of the Meth Project, perceived susceptibility could include the likeliness that a person believes he or she will use meth. Perceived severity is “the degree to which a person believes the consequences of the health problem will be severe” (15). The Meth Project attempts to influence perceived severity through graphic imagery of meth users who have succumbed to long-term effects and images of situations that could be consequential to meth use (10). Perceived benefits in the Health Belief Model refer to the positive consequences of partaking in the behavior change (15). Perceived barriers are the negative consequences that the person understands may result from the behavior change (15). The Health Belief model makes several assumptions that the Meth Project also relies onto promote its message. A few of these assumptions are that external, environmental influences are minimal and decision-making is predictable (16). Furthermore, the Health Belief Model assumes that “… an individual’s attitudes related to health behaviors can be predicted and appropriate intervention to change these attitudes can be initiated to obtain the desired behaviors or outcomes” (16). The Meth Project does not consider how the individual’s decision-making process may be influenced by social or other external factors or that an individual may not make decisions on rational thinking. The Meth Project also assumes that their target audience will be able to make behavioral changes based on the information they present, another assumption in the Health Belief Model (16). The Meth Project fails to acknowledge the irrationality and unpredictability associated with adolescence. Another flaw in the application of the Health Belief Model is that there lacks clear recommendations or behavior change, can teen can take. By relying on the Health Belief Model, the Meth Project fails to understand the irrationality of human behavior and any societal, environmental, or group-level influences.
Critique 3-Psychological Reactance Theory
The failures in the Meth Project to show a significant decline in reduction of meth use in teens could also be attributed to reactance theory. When an individual feels that his or her “…freedom to decide autonomously, to form their own opinions, to hold various attitudes (or not at all), and to do what they feel free to do”, he or she may “…experience reactance, a motivational state aimed at restoring the threatened freedom” (17). Research shows that individuals are less prone to exhibit psychological reactance when the message comes from a credible and similar source. Because teens often feel that the images in the advertisements run by the Meth Project are exaggerated or not credible, they may exhibit reactance, or a “boomerang” effect (14). The exaggerative imagery in the advertisements may also cause the teen to be unable to identify with the character in the ads. The lack of similarity may cause the teen to disassociate with the message and disregard it as he or she may feel that it does not apply to them. As the ads are aiming to change and control behavior associated with drug use, adolescents may feel a need to rebel against the entities trying to control behaviors. Additionally, research shows that the fear appeal was successful with parents and prompted child-parent conversations about meth use (18). While the campaign opened dialogue about drug use, a positive consequence, it is likely that some teens may have responded with reactance and rebellion in response to authoritative figures.
A Proposed Intervention
The Meth Project, though with faults and ambiguity in its effectiveness, has been successful in dispersing its messages and in obtaining grants and funding. Thus, I would not propose a completely new intervention, but rather modify the existing campaign by addressing its criticisms. First, instead of relying only fear to scare people into avoiding meth, it should also include an element to promote self-efficacy, the belief that a recommended action will reduce the threat associated with fear. Second, while the Meth Project, like many public health interventions, relies on the Health Belief Model. The underlying assumptions in the Meth Project advertisements, however, do not take into account external factors, social influences, or the irrationality behind decision-making. Finally, the message being delivered to adolescents, especially, should not invoke psychological reactance. This campaign should aim to use fear appeal in an effective, evidence-based method, expand upon the health belief model by addressing group-level dynamics and incorporating an understanding of environmental factors, and should take action to minimize the effects of psychological reactance theory. To address these criticisms, I would include in the advertisements credible, applicable information about meth, its prevalence, and consequences of its use. These messages would also not be based on individual decision-making or encourage teens to take a recommended action that sets them apart from their peers or in social settings. Additionally, the messages should be delivered by a similar, relatable source as to minimize reactance. To do this, I suggest using a diverse group of messengers so that every teen finds characteristics that he or she identifies with. Also, rather than simply showing or telling teens situations to avoid, a behavior that can trigger the boomerang effect and reactance, the advertisements should activate viewers to take on a different health behavior that does not involve the use of using meth. The message should not be about the hazards and dangerous situations that meth use can result, but rather about the advantages and benefits of not using meth.
Intervention—improving self-efficacy and taking action
As mentioned earlier fear appeal is not ineffective, however, the message, if not delivered appropriately will have unintended consequences. “Fear-appeal messages will be most effective if they are interesting, attention capturing, novel, relatively unknown topics, culturally sensitive, and cause the recipients to initially feel good about themselves, later sensitize them to their own risk, and then have their unhealthy point-of-view dispelled with empowerment” (12). In addition to a fear component about the consequences of meth use, the campaign should include a recommendation of an action. For example, the message could include a comparison of an individual who chooses to use meth and also of the same individual in a situation where he or she says not when presented the opportunity to use meth. The advertisement could first show the character declining an opportunity to use meth. Then, it could include a rewind back to the decision-making moment, and show the consequences of the character choosing to use meth. In the comparison, the individual can be learning behaviors to avoid meth use, learning the dangers, and making an active resolution to avoid situations that lead to meth use, or having a conversation with a peer about the situation. Similarly, self-efficacy could be encouraged by providing a story of how saying no to meth led to little consequence. The viewer should realize that saying no to meth use is simple, easy to do, and of no consequence. Essentially, the life of the character goes on just as it would have or even better than if had he or she not been a situation where the opportunity to use meth was present.
Intervention—Modeling and social influences
Use of the Health Belief Model in the Meth Project involves the assumption that behavior is rational and individual. Without understanding group-level dynamics, social factors, and irrational behavior, the motivation that Meth Project pursues to not use meth, falls short. To account for the influences of group dynamics, the advertisements use in the Meth Project can be modified to show group-level decision-making avoiding the use of meth. An advertisement could show a group of peers avoiding a social situation where others are using meth and suffering the consequences of meth us. The Meth Project can incorporate an understanding of social learning theory. In Social Learning Theory, behavior is learned through observation of the environment (19). Behaviors can be learned through modeling. Because “messages perceived as ineffective (or having a negative impact) are unlikely to prevent, and may actually facilitate, risky behavior” (20), portraying health behavior may promote teens to model them. Therefore, rather than anticipating deterrence of meth use by showing gruesome consequences to avoid, the incorporation of recommended actions and the portrayal of characters avoiding situations with meth and partaking in other suggested activities, behaviors is more likely to promote healthy behaviors.
Intervention—an emotional response
Evidence of reactance has already been observed among adolescents targeted in the Meth Project ad campaigns (14). In the Meth Project, the graphic images showing the filthy environments, violent behaviors, and detrimental biological effects that situations with meth use can lead to have led viewers to “question the level of realism” portrayed in the ads. As the theory of Psychological Reactance is based on four constructs, freedom, threat to freedom, reactance, and restoration of freedom, having an intervention that minimized reactance would first involve minimizing the perceived threat to freedom (20). In the Meth Project, therefore, having an intervention that minimizes reactance would involve invoking feelings of emotion that help teens identify with others who avoiding meth. Research has shown that “we feel emotions before we can engage cognitive interpretations” (21). Appealing to emotion and modeling can both help reduce reactance. Application of this in the Meth Project would involve character portrayals that are highly relatable. Viewers should not feel that meth addiction or situations with meth could never happen to them. Employing tactics to precipitate positive emotion, rather than otherness or anger, would have a stronger influence in conveying a message.
The Meth Project has been recognized as an effective campaign to discourage meth use. Its wide spread reach and use of exaggerated graphic images have also exaggerated the public’s perception of meth. Because of a downward trend in meth use prior to implementation of the Meth Project, it is hard to gauge, appropriately, its success. The Meth Project is based on behavioral theories, such as the Health Belief Model, that do not consider important factors involved in decision-making, such as external influences and reactance. Though the Meth Project is not unquestionably effective, modifications to incorporate the deficiencies would improve its effectiveness. The interventions suggested, such as incorporating recommended actions, approaches showing group decision-making, and invoking an emotional response to help viewers identify with the advertisements, could help make the Meth Project, not just a well-funded campaign, but also one considered most successful.
- Health Development Agency. The effectiveness of public health campaigns. Consumers and Markets 2004; 7: 1-5.
- King R. S. The next big thing? Methamphetamine in the United States. The Sentencing Project 2006; 1-41.
- The Meth Project. About Us. The Meth Project. http://www.methproject.org/about
- Montana Meth Project. About us. Montana Meth Project. http://montana.methproject.org/About-Us/index.php
- National Institute on Drug Abuse. Research Report Series: Methamphetamines. Rockwell, MD: National Institute of Health, U.S. Department of Health and Human Services, 2013.
- Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Finding. Rockwell, MD: Center for Behavioral Health Statistics and Quality, 2013.
- Semple S.J, Grant I., Patterson T.L. Utilization of Drug Treatment Programs by Methamphetamine Users: The Role of Social Stigma. The American Journal on Addictions 2005; 14:367-380.
- National Association of Counties. The Meth Epidemic: The Changing Demographics of Methamphetamine2007; 1-12.
- Anderson M. Does Information Matter? The Effect of the Meth Project on Meth Use among Youths. Seattle, WA: Department of Economics, University of Washington, 2010.
- The Meth Project. View Ads. The Meth Project. www.methproject.org/ads/
- Siebel T. and Mange, S. The Montana Meth Project: ‘Unselling’ a Dangerous Drug. Stanford Law & Policy Review 2009; 20: 405-416.
- Williams K. C. Fear appeal theory. Research in Business and Economics Journal 2012; 5: 1-21.
- Witte K. Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs1992； 59：329-349.
- Harding A. Benefits of graphic anti-meth ads questions. Net York, NY: Reuters http://www.reuters.com/article/2008/12/19/us-anti-meth-idUSTRE4BI5S620081219
- Individual health behavior theories (pp. 35 -49). In: Edberg, M. Essentials of Health Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.
- Thomas L. W. A critical feminist perspective of the health belief model: implications for nursing theory, research, practice, and education. Journal of Professional nursing 1995; 11:246-252.
- Silvia, P. J. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.
- The Partnership at Drugfree.org. Review Faults Montana Meth Project Ads. http://www.drugfree.org/join-together/drugs/review-faults-montana-meth
- Bandaru A. Social Learning Theory. New York, NY: General Learning Press, 1971.
- Chen Y. The effect of psychological reactance on acceptance of campaign message: A case of “stop texting while driving” campaign in college students. Graduate Theses and Dissertations 2013; paper 13405.
- Rains S. A., and Turner M. M. Psychological Reactance and Persuasive Health Communication: A Test and Extension of the Intertwined Model. Health Communication Research 2007; 33:241-269.