Challenging Dogma - Spring 2009

Thursday, May 14, 2009

Failure of the “Above the Influence” Campaign-Grace Yang

Despite the efforts of various anti-drug campaigns, there has been no change in the prevalence of youth drug use from 2005 to 2007 (1). The National Youth Anti-Drug Media Campaign attempted to combat youth drug use through its Above the Influence (ATI) initiative. This intervention uses TV, radio, print, and Web-based advertising to prevent and reduce youth drug use. ATI fails to accomplish its goal of reducing youth drug-use because it neglects social factors that are involved in youth behavior, disregards effective marketing strategies, and stigmatizes youth who use drugs.

An ATI advertisement that is entitled “Dog” shows a scenario where a young girl is in the kitchen and she hears someone call her name. She turns around and sees that it is her dog that is talking to her. Her dog expresses his disappointment in the fact that she smokes marijuana. In response to what her dog has said, the young girl looks like she feels overwhelmed with guilt because she failed to meet the expectations of her dog.

Another ATI commercial is called “Pony.” The advertisement shows three teenage boys walking in a field towards a horse. One teenager approaches the horse, pulls its tail, and gets kicked in the shin. The second boy does the same. The third teenager sees the pain that the other two are in and walks away as the adult narrator says, “You know a bad idea when you see one. Live above weed.”
The final example of an ATI advertisement is called “Achievements.” The commercial shows various happy teenagers saying things about themselves that they are proud of. However, they are actually things that people would normally be ashamed to admit. One teenager says that she received straight D’s. Another says that she made her mother cry. A different teenager says that he stole from his younger sister.

The ATI intervention wastes scarce resources by designing and implementing a campaign that fails on many levels. First, the campaign neglects to address social factors that influence health-related behavior. Second, it fails to use marketing techniques to induce behavioral change. Finally, it stigmatizes youth, creating another barrier to drug-free behavior. This paper will discuss these three aspects that result in the campaign’s failure.

Above the Influence Disregards Social Norms, Expectations, and Networks
The ATI campaign fails to change behavior because its advertisements do not address the importance of social norms, expectations, or networks. The behavior of large groups can be changed by understanding these important influences. This is especially true for adolescents. However, ATI fails to address behavior from these social perspectives, resulting in a weak and ineffective campaign.

Interventions must account for social norms, particularly when dealing with youth. Social norms are general rules that are understood and observed by a given group, community, or society (2). These include simple concepts that do not have severe consequences if people deviate from them, such as washing hands after using the bathroom. Other norms are more serious in nature, resulting in grave repercussions if broken, such as not driving while under the influence of drugs or alcohol. Whether these rules are perceived as trivial or serious, social norms play a large role in people’s behavior. The norms of peers are especially important to youth. For example, adolescents are also more likely to use condoms if they believe that their peers use them (3). This shows that the normative behavior of peers influence the boundaries for acceptable behavior rather than individual beliefs and attitudes. Therefore, if public health campaigns change the perceived social norms regarding a certain behavior, their effectiveness would substantially increase. However, ATI disregards the impact that peer behaviors have on individual adolescent behavior.

Another important social influence is social expectations, which is defined as whether an individual’s social groups of influence approve or disapprove a behavior (3). The expectations of peers have been shown to greatly affect health-related behaviors. For example, youth who associated with deviant peers were more likely to be delinquent themselves and use drugs (4). Also, peer perceptions more strongly affected sexual behavior than parental monitoring (3). It is clear that the opinions of peers have a large influence on the behaviors of youth. Despite these findings, ATI rejects the importance of peer approval or disapproval and consequently fails to change youth drug-use behavior.

The ATI media campaign also fails to focus on social networks and its influence on behavior. Social networks are comprised of individuals who influence one another, such as family, friends, or co-workers. The nature of the relationships between people in social networks can have a great impact on the way that people behave. Each person in a social network has a particular role to fill when in a group setting (2). These roles are specific parts that people play when involved in group activities. For example, mothers, fathers, and children all play distinct roles in a family. Similarly, peers play a particular role in an adolescent’s social network. Certain roles are more influential than others, especially regarding health-related behaviors. Peer influence is a significant predictor of adolescent smoking, whereas parental influence has little effect (5). Moreover, the finding that condom use typically declines with age except among youth who perceive that most of their friends use condoms illustrates the powerful role that peer behavior can have on risk-reducing behavior (3).

Conducting formative research, which is research that is conducted before a program is designed and implemented, is an essential tool for creating an effective campaign. The roles of different people in the lives of youth must be researched prior to developing a campaign to better understand which social groups that have a greatest amount of influence. The developers of Florida’s anti-smoking campaign called “Truth” spent months researching and interviewing youth (6). This is one of the key elements that contributed to the success of the campaign. ATI clearly did not conduct enough formative research with youth because it fails to take into consideration the influential role of peers.

When addressing social norms and expectations, it is important to focus on the beliefs and opinions of individuals, rather than non-human beings. Similarly, an individual’s social network consists of people, not animals. Twenty five percent of the current ATI advertisements depict a conversation regarding drug use between an individual and a non-human character. The ATI advertisement called “Dog” is an example of the campaign’s ignorance of the social factors that influence their target population. The scenario depicted in the advertisement is unrealistic and likely to have no effect on drug use, or more likely to have unintended consequences (i.e., increase the probability that adolescents will try or continue to use illicit drugs) (7). Failing to highlight the importance of social factors in decision making results in an ineffective or even counter effective intervention.

Above the Influence Fails to Market Anti-Drug Behavior to Youth
The ATI campaign fails to utilize key components of social marketing to appeal to adolescents. Marketing is a process in which two or more parties each have something to exchange. On one side of the exchange is the party that promotes and sells a product. On the other side are consumers who pay a price to buy the product (8). Marketing is a novel strategy that should be utilized in public health interventions aimed at behavior change. In order to successfully market a product, formative research must be conducted to better understand the targets population’s preferences and needs (9,10). The developers of the ATI campaign failed to thoroughly understand which benefits the target audience values the most. Therefore, they were unsuccessful in creating a desirable product that provides those benefits.

One of the key elements of marketing is the product, which refers to the behavior that is being promoted (8). Product also refers to the benefits associated with the behavior (10). ATI fails to present anti-drug behavior as a product. Rather, it merely presents it as a means for healthier living. Packaging health-related behavior as a valued product that the target population is willing to purchase is a more effective way to induce behavioral change (11).

Price is another key element of marketing. This refers to the costs of adopting a certain behavior. Even in a voluntary exchange, there is a price for a new behavior (9). Price often entails intangible costs, such as embarrassment and decreased pleasure associated with denying drug use. There is also a psychological cost related to change, especially when altering habits. ATI ignores the sacrifices that teenagers make when they decide to be drug-free. These sacrifices include being alienated and losing friends. A constricted social network can be a serious cost to adolescents, but ATI fails to address these costs, rendering the campaign ineffective.

Another aspect of marketing that makes it such a successful strategy is that it puts the decision making in the hands of the consumers. This is especially relevant when the target population is youth because freedom and autonomy are core values that they highly regard. Formative research shows that youth do not want to be told what to do (6). They want to make their own decisions and any threats to their independence is likely to result in rebellion. The success of Florida’s anti-smoking campaign, called “Truth,” is attributed largely to the fact that it marketed anti-smoking behavior as a desirable product. But it was also successful because it had a message other than “don’t.” The goal of marketing is to influence a target population, while allowing them to voluntarily adopt the health behavior that is promoted. What makes marketing so powerful is that the population is in full control of the decision making process. Rather than trying to sell a certain behavior change to youth, ATI advertisements tell them to adopt it. They remove the element of freedom, which is an ineffective way to influence adolescents. For example, the Partnership for a Drug Free America produced anti-drug public service announcements with “just say no” messages, which had a negative effect on drug use (7). The ATI commercial called “Pony” is an advertisement that would result in a similar negative reaction in youth. The tone of this message is one of authority, which is likely to evoke a rebellious response in teenagers in an attempt to preserve their autonomy. The commercial has the potential to cause youth to try drugs in an act of rebellion because the advertisement essentially tells them not to use drugs because it is a bad idea. This demonstrates the ineffectiveness of telling youth what to do, as opposed to providing them with tools and allowing them to make the decision on their own.

The Above the Influence campaign fails to provide youth with new information and allow them to utilize the information that is presented to make their own decisions. Marketing is a proven way to induce behavioral change by allowing target populations to make healthier decisions on their own. This strategy is especially effective on youth because autonomy is so important to them. However, ATI disregards the power of marketing and the value that youth place on autonomy, thereby creating a fruitless campaign.

Above the Influence Stigmatizes Youth for Their Drug Use
ATI overlooks the negative impact that stigmatizing youth has on their behavior. Negatively labeling youth for their drug use is counterproductive because it creates a barrier for behavioral change. Even when youth had different opinions about smoking, there was an overwhelming consensus regarding their abhorrence for anti-tobacco efforts that pass judgment on tobacco users (6). This shows that ATI is not only ineffective, but counterproductive in their efforts to decrease youth drug use. Youth’s strong aversion to stigmatization makes them more likely to continue or start a behavior, rather than prevent or change an existing behavior, in response to negative labeling. Therefore, ATI fails in its attempt to change behavior by utilizing stigmatization.

The ATI intervention is also counterproductive because of the negative emotional effects that stigma has on vulnerable populations. In the context of ATI, vulnerable populations include youth who already use drugs. The effect of stigma on people with mental illnesses highlights the detrimental effect of stigma. One of the most adverse effects of the stigma of mental illness is that it leads many afflicted with such illnesses to believe that they are failures or have little to be proud of. A fear of rejection by others can have serious negative consequences, such as more constricted social networks, poorer life satisfaction, and unemployment. As a result, self-esteem is negatively affected and many people with mental illnesses conclude that they are less capable than others (12). Moreover, stigma is a barrier for individuals with depression to adhere to treatment regimens. Compliance with antidepressant drug therapy is predicted by levels of perceived stigma (13). Individuals with mental illness experience such high levels of social stigma that the Surgeon General emphasizes the importance of reducing stigma as a barrier to improved health outcomes (12). The influence of stigma is so strong that it diminishes self esteem and outweighs the therapeutic value of taking medication. For these reasons, ATI’s use of stigmatization is counterproductive in their attempt to prevent and stop youth drug use.

Stigma is also a reason that people fail to disclose their HIV-positive status. There are salubrious advantages of disclosing one’s HIV-positive status. First, an individual who is HIV positive can reduce potential infections of sexual partners, consequently preventing the spread of the virus, by disclosing their HIV positive status (14). Second, disclosure is also a means to receive social support to facilitate coping with the disease process (15). However, disclosure can also lead to stigma and shame (16). The traumatizing power of stigma associated with HIV overrides the healthy effects of disclosure (17). Clearly, stigma has a strong influence on health behavior. Despite the advantages of disclosing one’s HIV-positive status, the fear of stigma is so overpowering that it negates the benefits of disclosure.

The ATI campaign’s attempt to prevent and reduce drug use is futile because it utilizes stigmatization to reach this goal. Stigma is shown to have detrimental effects in people who have mental illnesses and are HIV-positive. Stigma causes those with mental illnesses to feel less worthy than others, exacerbating their condition. It also prevents people with depression from adhering to their medication regimen. Lastly, stigma creates barriers for people who are HIV-positive to make healthier decisions for themselves. Another example of stigmatization is seen in the ATI “Achievements” advertisement, which negatively labels youth who use drugs as poor students, cruel to their parents, and deceitful to younger siblings who look up to them. Stigmatizing youth for their drug use will only lower their value of self-worth, creating further barriers to behavior change. This use of stigmatization is detrimental to the campaign’s goals of reducing youth drug use.


The ATI campaign fails in its attempt to prevent and reduce youth drug use because it overlooks key components for successful behavior change. The campaign disregards key social factors that influence health-related behavior. It also fails to use marketing strategies to sell drug-free behavior to youth. Rather, it poses a threat to their autonomy by dictating their decisions. Lastly, the content of the messages is counterproductive because it stigmatizes youth, which creates a barrier to behavior modification. Media campaigns are promising means to induce large scale behavioral changes. However, the ATI campaign fails to take advantage of the potential that the mass media has to influence healthier behaviors in youth. ATI dismisses the growing evidence in the literature from various fields that provides strategies for effective interventions. Consequently, it misuses valuable resources to create an intervention that fails on multiple levels.

“Unhooked”: Counter-Proposal to the “Above the Influence” Campaign

Unhooked: Alternative Anti-Drug Intervention

The Above the Influence (ATI) campaign attempts to prevent and reduce youth drug-use. However, it fails on many levels because it does not address important influential social factors, neglects effective marketing strategies, and stigmatizes youth who use drugs. This paper proposes a novel intervention, called Unhooked, to counter the failings of ATI.

Unhooked is a web-based campaign that addresses adolescent drug use from a social and behavioral science perspective. This intervention is superior to ATI for three reasons. First, it approaches behavior from a social context by incorporating the influence of peer groups. Second, the intervention utilizes marketing strategies to promote drug-free behavior as a desirable product. In order to effectively advertise and promote the product, it takes advantage of various media outlets frequently used by youth, such as Facebook, MySpace, and YouTube. Third, the content presented in the intervention is thoughtfully developed in order to avoid stigmatization.

This campaign is comprised of five main components: (1) web groups, (2) a media library, (3) gear, (4) fact sheets, (5) and forums. Web groups are online “clubs” that are led by peer leaders of the target population. Peer leaders are youth who demonstrate leadership skills and have a significant influence over the target population. Leaders create a web group for each of their schools in order to serve as a community of support for those who want to be drug-free. This creates a special social network of youth who are committed to being drug-free. The Unhooked media library consists of videos and commercials created by youth and advertising professionals to decrease the allure of drug use. Commercial topics include the difficulties of saying no to drugs and the social consequences of doing so. Gear is an essential component of the intervention because it facilitates the promotion of drug-free behavior by creating a brand that is easily identified and consequently desired by youth. Lastly, the educational element, comprised of fact sheets and an educational forum, provides youth with information about drug use so that they can make an informed decision about their behavior.

Unhooked Addresses Social Influences Associated with Youth Drug Use
The Unhooked campaign incorporates peer norms and expectations because social factors play important roles in youth behavior. The influence of peers is one of the most prevalent risk factors for early onset or increased substance use during adolescence (18). A key strength of the Unhooked intervention is that it addresses peer norms, a powerful influence on adolescent health-related behavior. Norms that encourage drug use result in greater rates of youth substance use (19). Expectations, which encourage or discourage drug use, also influence adolescent substance use. When teenagers’ peers use drugs and expectations for drug-use increase, teens are more likely to use drugs (20,21). For these reasons, it is necessary to acknowledge the effect of social norms and expectations on youth behavior and address drug use with this phenomenon in mind.

Web groups are a means to create social norms and expectations that deter adolescents from using drugs. They also provide a social network for youth who are already drug-free or would like to be drug-free. Having peer leaders create these groups is an effective strategy to reduce drug use because smoking prevention programs led by peers were successful in reducing adolescent smoking onset rates (22). School health education programs led by peers were as effective or more effective than programs led by adult leaders (23). Peer leaders who advocate for drug-free behavior change social norms and expectations that encourage and accept drug use to those that discourage it. This creates a shift in the perceived normative behavior of youth and provides a network of support for youth who would like to be drug-free. Therefore, web groups led by peers are effective means of compelling youth to change their behavior.

Unhooked Markets Anti-Drug Behavior
Marketing has been used in various fields for decades as a powerful tool to evoke behavioral change. However, public health professionals have yet to incorporate this effective strategy into their interventions. Unlike ATI, Unhooked uses components of marketing to reach its target population. Adolescents are often the target of advertising and marketing efforts because they are easily persuaded and influenced by their messages (24). Youth who were exposed to more alcohol advertisements consumed higher amounts of alcohol on average than those who saw fewer advertisements. Youth in high advertisement environments also increased their alcohol consumption into their late 20’s, while alcohol consumption for youth in low advertisement environments leveled off (25). This illustrates the persuasive and lasting effects of marketing on health-related behaviors.

Marketing is a prevailing force on youth behavior. For this reason, Unhooked integrates marketing strategies into its anti-drug campaign. This intervention uses the internet to disseminate media messages about drug-use. The videos and commercials can be easily accessed on the Unhooked website, and on social networking websites that youth frequently use, namely Facebook, MySpace, and YouTube. The Unhooked media library is created by youth so that drug-free behavior is advocated from the perspective of peers, rather than adults. This minimizes any negative reactions that youth may have against authority and decreases the likelihood of unintended consequences, such as rebellious drug use. The media clips demonstrate the costs of adopting a drug-free lifestyle, such as potential alienation from friends who use drugs. The videos and advertisements show that although youth may lose friends in their social network, there are still countless youth who commend and support their decision to reject drugs.

Unhooked also promotes healthy drug-free behavior through its line of various gear, including bracelets, notebooks, and t-shirts. Unhooked takes advantage of branding, a strategy that creates a set of positive associations with a product. The LIVESTRONG Global Cancer Campaign is a well-recognized campaign that has effectively used gear to brand their efforts for cancer control. Using gear as promotional items marked with the Unhooked logo creates a positive relationship with youth, which results in brand awareness and preference (24). This often leads to brand loyalty, which leads them to desire the product of drug-free behavior. This is a clever tool used by the marketing industry that should also be used in public health interventions.

Unhooked Incorporates Non-Stigmatizing Content
Interventions with stigmatizing content are counter-productive because stigma creates barriers to behavior change. Stigma precludes those living with depression and a positive HIV status from engaging in healthy behavior (11-16). Similarly, the stigma of being overweight and focusing on negative body images deters some youth from losing weight (26). Formative research conducted with youth show that rather than being judged for their behavior, youth want facts to make their own decisions (6). Therefore, it is important that public health professionals pay close attention to the content of their intervention’s message.

Unhooked uses caution when creating the messages that are conveyed to youth about drug use. It is essential that the tone is non-judgmental and the message does not contain stigmatizing content. Because youth are prone to negatively react to stigma, the Unhooked website refrains from incorporating negative labeling into the content of its intervention. This is accomplished by staff members who regulate and remove stigmatizing content that may be posted on the website by the public. This is done strictly to uphold the positive and safe online environment that Unhooked creates for youth. Instead of using to stigma to try to effect behavioral change, Unhooked provides youth with educational tools to receive information and advice about drugs. The website has fact sheets about various illicit drugs and the effects of drug use. There is also an educational forum where youth can ask health professionals any questions they may have about substance use. If there are any question about drugs or behaviors that the fact sheets do not answer, youth are welcome to ask health care providers for additional information. An advantage of using the forum to inquire about the consequences of drug use is that youth can remain anonymous when posting questions to minimize any feelings of stigmatization from peers or the online community.

Youth drug-use is an individual and societal level problem that must be confronted with innovative strategies. Unhooked is a novel alternative to ATI, which fails to decrease rates of risky youth behavior. Unhooked addresses the three key failures of the ATI campaign. First, it addresses the social influences that impact youth behavior by facilitating web-based social networking. Second, it uses marketing techniques to sell drug-free behavior as a desirable product by using media and gear as promotional tools. Third, it contains non-stigmatizing content that informs youth about drug use so that they can make an educated decision on their own. Understanding the target population is a primary strength of the Unhooked intervention, which is based on social and behavioral theory. In order to decrease the prevalence of youth drug-use, it is necessary to stop wasting resources on ATI and implement Unhooked.


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