Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Saturday, December 8, 2007

The Cage Your Rage Campaign And Bar Violence: Is “Ultimate Bar-Fighting Stupidity” Really the Target?—Deinera Exner

INTRODUCTION

Youth violence constitutes a growing public health problem (1), and the link between alcohol consumption and aggression in male youths has been well-documented in the literature (2-12). In Alberta, Canada, rates of victimization in alcohol-related incidents are significantly higher than the national average: 13.4% of Albertans aged 18 and over report being pushed or shoved by a person who had been drinking prior to the incident (national average 10%), and 5.4% report being physically assaulted (3.2%). As a result of this violence, the Alberta Gaming and Liquor Commission (AGLC) recently created the public awareness campaign Cage Your Rage: A New Campaign to Reduce Bar Violence, focused on “discourag[ing] young men from fighting when drinking at bars and nightclubs” (13). However, the campaign relies heavily on the Health Belief Model (HBM), and in doing so, ignores three primary predictors of bar violence: the impact of alcohol on decision-making, the aggression-facilitating characteristics of individuals, and the situational context, including both peer groups and the bar environment itself (12). Because of these reasons, this campaign is inherently flawed, and is predicted by this author to be a public health failure.

The Cage Your Rage Campaign: Overviews and Origins

According to Fred Lindsay, Solicitor General and Minister of Public Security, “violence in and around licensed premises is a growing concern in Alberta” (13). Thus, following the 2006 Roundtable on Violence In and Around Licensed Premises, the AGLC created the Cage Your Rage campaign, which “asks patrons to think carefully about the consequences of violent behavior around bars or lounges” (13). According to the AGLC, Cage Your Rage is “part of a broader social marketing strategy [to] address problem drinking behaviours that may contribute to violent situations, and to encourage a culture of drinking in moderation” (13). The campaign, which consists of radio ads, posters in bar restrooms and liquor stores, and ads on movie theatre screens and TV screens in taxi cabs, primarily targets males, as they “are highly social, and research shows there is a high rate of drinking and heavy drinking (e.g. binge drinking) among Albertans aged 18-24” (13).

The ads, created by “analyzing the target audience’s media habits,” and designed to “grab the attention of young men” (13, 14), contain 5 key messages, all describing situations that “occur in or around bars and that can lead to violent situations” (13); for example, one message states “you vs. the guy who wore the wrong jersey and benches more than you weigh.” For a complete listing of ads and key slogans, please see (14).

It should be noted that, while barroom- and alcohol-related violence can be considered two separate entities, this particular campaign often blurs the distinction, and seems to use the phrase bar violence as a more inclusive moniker for alcohol-related violence. In addition, past research has estimated that 65% of all bar violence incidents are alcohol related (8). Thus, this paper will primarily focus on alcohol-related violence and decision making, both within the bar setting and beyond.

To “appeal to the target audience” (13), the design of the print ads imitates a fight poster, and each ad is topped with the image of a fight belt containing the phrase “Ultimate Bar Fighting Stupidity.” To assess the effectiveness of the ad design, focus groups and street-level intercepts were used to test the target audience’s response to sample posters in bar settings, and, based on feedback from these groups, the concept was deemed effective. The two-month campaign began on June 18, 2007; however, no information is currently available that discusses the actual effectiveness of the campaign.

Health Belief Model

To discourage male youths from participating in alcohol-related violence, the Cage Your Rage campaign uses the Health Belief Model (HBM), an individual level model that argues behavior is determined by six factors: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy (15). From these factors, the individual constructs a behavioral outcome by weighing the perceived benefits of the action against perceived costs or barriers (16). So, if the youth in question feels that they are both susceptible to alcohol-related violence and that the consequences of this violence are sufficiently severe, and/or feels that doing the behavior has perceived benefits and few barriers, they will form an intention, which will lead to the behavior. It is at the intention stage that this campaign operates, by asking individuals to form an intention not to participate in violence either prior to entering the bar environment (e.g., posters in liquor stores, radio ads), or while they are in the bar environment (i.e., posters in bar restrooms), and to translate this intention into the desired behavior if they are confronted with an aggression-inducing situation.

You vs. The Guy: A Fundamental Misunderstanding of HBM Principles

Before arguing why the HBM is an ineffectual model for this campaign, it is first important to gain a sense of how the campaign uses the HBM, since this informs many of the arguments against its use. Since all key messages operate within the same general theme (i.e., you vs. the guy), I will use as my example the key message mentioned previously: “you vs. the guy who wore the wrong jersey and benches more than you weigh.”

In applying the model to this campaign, the five key messages attempt to increase the perceived severity of the anticipated consequences. However, the other primary components of the HBM are generally neglected. By excluding any mention of alcohol, the poster does not adequately address susceptibility. When reading these messages, one must ask to what the campaign would like the individual to feel susceptible: Guys wearing the wrong jersey? Guys who work out? Or perhaps, oneself? These questions convey the confusion inherent in such a vague statement, and demonstrate that the message the campaign is trying to convey (i.e., is the individual susceptible to aggression in this environment if provoked?) is not easily comprehended.

Inasmuch as the campaign fails to express perceived susceptibility, the individual is also left wondering about the benefits and barriers of this behavior. This confusion stems in part from a lack of clarity in specifying the targeted behavior; however, while one may be able to implicitly determine the benefits of adopting the behavior, a realization of the barriers, and how to overcome them, is much more difficult, since many of these barriers arise from the situational context in which the violence occurs.

Finally, while a mass media campaign is sufficient to provide a cue to action (16), no thought is given to self-efficacy. In this case, self-efficacy, or the individual’s confidence in his ability to do the action (15), is undermined both by the lack of consideration of the individual’s personal characteristics (e.g., ability to control aggression under the influence of alcohol), as well as of the situational context (e.g., influence of peer groups, social norms of the bar).

Clearly, the campaign fails to adequately consider the components of the HBM. However, the campaign is most flawed in its failure to realize the contradiction of the three primary predictors of bar violence—the effect of alcohol on decision-making, individual characteristics and situational context—with the tenets of the HBM, and it is this argument that this paper serves to explore.

RATIONAL THOUGHT IN THE BAR ENVIRONMENT: AN UNLIKELY CORRELATE

Besides asking individuals to weigh barriers and benefits against perceived severity, the HBM is also a rational belief model, in that it “assumes that human behavior is determined by an objective, logical thought process” (16, p.128). The campaign errs, then, in assuming that the targeted individual is capable of rational thought, as this discounts the influence of alcohol. It is well-documented that alcohol impairs the logical thought process (7,17-18,20-21), and several studies have shown that alcohol interferes with cognitive functioning, including decision-making, even in social drinkers (17-21). Furthermore, even in those individuals who normally would not participate in violent activities, the use of alcohol can generate less negative attitudes towards risky behaviors (20).

Alcohol Use and Impaired Cognitive Functioning

George, Rogers & Duka (18, p.168) describe decision-making as “an emotional and cognitive process which involves the weighing up of potential costs and benefits of any particular action,” a definition akin to the crux of the HBM. However, in their study involving social drinkers, they found that participants under the influence of alcohol fail to “accurately assess the costs and benefits associated with a particular course of action,” due to effect of alcohol on executive cognitive functioning (18, p.168). In a similar discussion, Giancola & Corman (7) and Steele & Josephs (22) describe the effect of ‘alcohol myopia’, wherein “acute alcohol intoxication disrupts cognitive functioning, thus creating a ‘myopic’ or narrowing effect on attentional capacity” and so facilitates aggression by “focusing attention on more salient provocative, rather than less salient inhibitory, cues in a hostile situation” (7, p.649).

These effects of alcohol on cognitive functioning undermine both the use of the HBM, as well as the key messages of the posters. Under the influence of alcohol, individuals cannot accurately assess costs and benefits, key to the success of the HBM; thus, the use of the HBM in designing this intervention is both illogical and ineffective. Furthermore, individuals are less able to focus on inhibitory cues (i.e., the message on the poster). While some authors argue that, if an inhibitory cue is sufficiently salient, intoxicated persons may form more negative opinions about a certain behavior than their sober counterparts (20), it is unlikely a similar effect would be observed here. As the literature demonstrates, situations involving provocation are often precursors of alcohol-related aggression (2-6,10). Here, the ‘salient provocative’ cues are so strong that they are likely to far exceed the ‘salient inhibitory’ cues of the intervention, especially ones as ineffectual as found here. Thus, in this context, this author predicts that the alcohol myopia effect will attenuate the potential impact of the intervention.

Alcohol Use and Risky Decision Making

The effectiveness of this campaign primarily relies on the individual comprehending the perceived severity of alcohol-related aggression, and thus refraining from this behavior. However, Macdonald, Zanna & Fong (20, p.973) have previously found that alcohol intoxication may cause an individual to “generate less negative attitudes toward…risky behaviors and therefore cause that person to be more likely to engage in them, despite his or her knowledge of the attendant dangers.” So, while intoxicated, an individual may view the perceived severity of the action as low, despite his knowledge of the “attendant dangers” (20, p. 973). Thus, the HBM fails to accurately predict behavior, and the specific targeting of the perceived severity component of the HBM is especially ineffectual.

By ignoring the fact that targeted individuals are likely to be under the influence of alcohol, the campaign fails by assuming the individual is capable of rational decision-making, and that the individual will be able to judge his behavior as sufficiently severe.

INDIVIDUAL CHARACTERISTICS AND ALCOHOL-RELATED AGGRESSION

The neglect of individual aggression-facilitating characteristics present in this campaign is deleterious for several reasons. Firstly, by ignoring these characteristics, the campaign also ignores the concept of self-efficacy, a key predictor of behavior (16). Secondly, by failing to realize that certain individuals are more likely to participate in alcohol-related violence than others, and by not targeting this group specifically, the potential effectiveness of the campaign is weakened. Despite the disregard of these factors here, they have not been ignored in the literature: in a recent review, Graham et al. (23) found personality, attitudes, or other expectations of the drinker to be a primary cause of alcohol-related aggression.

Aggression-facilitating characteristics

Several previous studies (2-4,6,9-10,26) have demonstrated that individuals with aggressive personality traits, including individuals with high levels of trait anger (anger proneness), those with deviant attitudes, and those who exhibit hostility, impulsivity and concerns about power, are more likely to be involved in alcohol-related aggression (3,12,19). In its neglect of these individual characteristics, the campaign makes the assumption that all individuals are equally capable of controlling alcohol-related aggression in response to provocation. However, this is clearly not the case; for example, those with moderate to high levels of trait anger have been found to have low levels of anger control (i.e., are more likely to display aggression) while intoxicated (3), and can be considered predisposed to an aggressive reaction while under the influence of alcohol. Are the key messages found in this intervention, then, likely to dissuade this group from becoming aggressive? Unlikely, as the true problem lies in this group’s tendency to experience anger, which this intervention does not address. Though this is but one example, it demonstrates an incorrect target on behalf of the campaign: to truly reduce alcohol-related violence, the campaign must target individual characteristics that predispose that person to such aggression, and not the aggressive act itself. Furthermore, by assuming that all individuals are equally capable of controlling their anger while intoxicated, the campaign does not provide self-efficacy to those who cannot. As a result, those who feel that they are unable to do the prescribed behavior, the same people who are most likely to engage in alcohol-related aggression, may not try at all, rendering the campaign largely ineffective.

Alcohol expectancy theory

Individuals who expect that the consumption of alcohol leads to aggressive behavior, referred to by Goldman, Del Boca and Darkes as the alcohol expectancy theory (as cited in (3)), are more likely to be perpetrators of alcohol-related violence (2,8,11,24,26). As suggested by Quigley, Corbett & Tedeschi (8), this effect may stem from individual aggression-facilitating characteristics: individuals who possess aggressive traits are more likely to experience violence while intoxicated, and in turn this creates expectancies that alcohol leads to aggression. The individual is then involved in further aggressive incidents, and the concept is reinforced. However, by failing to mention alcohol, the campaign does not address any part of the alcohol expectancy theory, and in doing so, again does not support self-efficacy. Here, individuals who have been violent in the past, and who feel that this violence is a result of their consumption of alcohol, will not feel empowered that, while under the influence of alcohol, they can choose not to be aggressive. Once again, because they feel unable to do the behavior, they may not try to control their aggression at all.

THE SOCIAL ENVIRONMENT AND ALCOHOL-RELATED AGGRESSION

Despite evidence supporting the importance of social constructs (23,25,28), Cage Your Rage, through its use of simple slogans and individual-level key messages, ignores aspects of the multi-level social environment that may moderate aggressive behavior. The social environment, described by Graham, Bernards, Osgood and Wells (23, p.1570) as the “attributes that govern social interactions,” includes the effect of the individual’s peer group (e.g., acceptance of anti-normative behavior, social pressure), as well as the effect of the physical environment and social norms of the bar itself.

Peer Group

In their recent article, Wells, Graham, Speechley & Koval (25, p.934), state that “the social context may also play a role in explaining alcohol-related aggression, especially for young people whose behavior is influenced strongly by peers.” Though this thought is somewhat intuitive, as the notion that peers influence youth behavior is certainly not new, it represents another key predictor of alcohol-related aggressive behavior in male youths blatantly ignored by this campaign. By not providing information on how to deal with the effect of peer influence, the campaign either expects that the individual act autonomously in his decision, or leaves this as a barrier for the individual to overcome on his own. However, this lack of consideration is more a function of the campaign’s reliance on the HBM, as this model does not consider social context.

Beyond being a perceived barrier, the effect of negative peer-influence may also be a detriment to self-efficacy, as the individual may feel that with his peers present, he is not capable of achieving the desired behavior.

Physical Environment of the Bar

Aspects of the physical environment of the bar are also correlated with alcohol-related aggression: these include crowding, noise level, poor ventilation, smokiness, size of the bar, the neighborhood where the bar is located, and the type of furnishings (19,23). As suggested by Graham, Bernards, Osgood & Wells (23, pp.1569-70), these may contribute to aggression through factors “related to environmental irritants, for instance smokiness…and frustration and provocation due to crowding and congestion.” So, while the campaign alludes to the idea of general provocation (e.g., through the ‘wrong jersey’) it does not consider specific physical factors of the bar itself that may provoke or engender violence, despite evidence supporting the physical environment as an important predictor of bar-specific violence. Thus, the campaign leaves another barrier for the individual to overcome, by not providing information on how to deal with aggression in poor-quality physical environments. Going further, the campaign may have even considered aspects of the physical bar environment a fundamental cause of alcohol-related aggression (29), and attempted to correct these, instead of focusing on individual behaviors. However, the sole use of the HBM in this campaign limits the consideration of further social context, and thus intrinsically limits the campaign.

Social Norms of the Bar

A consistently cited progenitor of alcohol-related violence involves the social norms of the bar (11-12,19,23-28). These norms include the intoxication level of the bar (i.e., bar policies that encourage heavy drinking, such as inexpensive shots), sexual competition, aggressive staff (including the presence of bouncers), and permissive behavioral expectations (12, 23, 27). According to Quigley, Leonard & Collins (27, p.765) the social norms of the bar can “provide expectations about how to behave when drinking”; for example, a “clean well-kept bar with a helpful and friendly staff is less likely to suggest to drinkers that antinormative behavior is acceptable than a dirty and poorly maintained bar with an unfriendly bar staff.” Certain bars may also be more violent as a result of the clientele they attract, particularly, “hostile, under-socialized or risk-taking individuals” (12, p.1683). Due to its individual-level nature, the HBM in no way considers the importance of these social norms in predicting alcohol-related aggression. Again, these norms could be considered fundamental causes, which, if addressed, may prove more effective in decreasing alcohol-related aggression than attempts to change individual behavior. The campaign also does not specify that it specifically targeted bars more prone to alcohol-related aggression, or establishments that fit the profile of a ‘violent’ bar. Once again, by applying a generic approach to decrease alcohol-related aggression, the creators of this campaign further weakened an already questionable campaign.

Conclusion

Cage Your Rage is flawed on several levels, but primarily in its attempts to change behavior, considering neither the three primary predictors of bar violence nor the conflict of these predictors with the HBM. Because of this, the campaign wrongly assumes that the target of bar violence is ‘ultimate bar-fighting stupidity,’ and in doing so, renders this intervention ineffective.

REFERENCES

1. Ruttenberg H. The Limited Promise of Public Health Methodologies to Prevent Youth Violence. The Yale Law Journal 1994; 103(7):1885-1912.

2. Giancola PR, Zeichner A. Alcohol-Related Aggression in Males and Females: Effects of Blood Alcohol Concentration, Subjective Intoxication, Personality, and Provocation. Alcoholism: Clinical and Experimental Research 1995; 19(1):130-134.

3. Parrott DJ, Zeichner A. Effects of Alcohol and Trait Anger on Physical Aggression in Men. Journal of Studies on Alcohol 2002; 63:196-204.

4. Parrott DJ, Zeichner A, Stephens D. Effects of Alcohol, Personality, and Provocation on the Expression of Anger in Men: A Facial Coding Analysis. Alcoholism: Clinical and Experimental Research 2003; 27(6):937-945.

5. Zeichner A, Allen JD, Giancola PR, Lating JM. Alcohol and Aggression: Effects of Personal Threat on Human Aggression and Affective Arousal. Alcoholism: Clinical and Experimental Research 1994; 18(3):657-663.

6. Giancola PR. Alcohol-Related Aggression in Men and women: The Influence of Dispositional Aggressivity. Journal of Studies on Alcohol 2002; 63:698-708).

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12. Leonard KE, Quigley BM, Collins RL. Drinking, personality, and bar environmental characteristics as predictors of involvement in barroom aggression. Addictive Behaviors 2003; 28(9):1681-1700.

13. Government of Alberta. Cage Your Rage Backgrounder. Edmonton, AB: Government of Alberta. http://www.gov.ab.ca/acn/200706/216833FE9BEF6-0ECF-81D6-01A4883EC4C04B71.html.

14. Alberta Gaming and Liquor Commission. Cage Your Rage. Edmonton, AB: Alberta Gaming and Liquor Commission. http://www.aglc.gov.ab.ca/responsibleliquorservice/cageyourrage.asp.

15. Edberg M. Individual Health Behavior Theories (pp.35-50). In: Edberg M, ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

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17. Giancola PR. Executive Functioning: A Conceptual Framework for Alcohol-Related Aggression. Experimental and Clinical Psychopharmacology 2000; 8(4):576-597.

18. George S, Rogers RD, Duka T. The acute effect of alcohol on decision making in social drinkers. Psychopharmacology 2005; 182:160-169.

19. Graham K, West P, Wells S. Evaluating theories of alcohol-related aggression using observations of young adults in bars. Addiction 2000; 95(6):847-863.

20. Macdonald TK, Zanna MP, Fong GT. Decision Making in Altered States: Effects of Alcohol on Attitudes Toward Drinking and Driving. Journal of Personality and Social Psychology 1995; 68(6):973-985.

21. Leigh BC. Peril, chance, and adventure: concepts of risk, alcohol use and risky behavior in young adults. Addiction 1994; 94(3):371-383.

22. Steele CM, Josephs RA. Alcohol Myopia: Its Prized and Dangerous Effects. American Psychologist 1990; 45(8):921-933

23. Graham K, Bernards S, Osgood DW, Wells S. Bad nights or bad bars? Multi-level analysis of environmental predictors of aggression in late-night large-capacity bars and clubs. Addiction 2006; 101:1569-1580.

24. Wells S, Graham K. Aggression involving alcohol: relationship to drinking patterns and social context. Addiction 2003; 98:33-42.

25. Wells S, Graham K, Speechley M, Koval, JJ. Drinking patterns, drinking contexts and alcohol-related aggression among late adolescent and young adult drinkers. Addiction 2005; 100:933-944.

26. Tremblay PF, Mihic L, Graham K, Jelley J. Role of Motivation to Respond to Provocation, the Social Environment, and Trait Aggression in Alcohol-Related Aggression. Aggressive Behavior 2007; 33:389-411.

27. Quigley BM, Leonard KE, Collins RL. Characteristics of Violent Bars and Bar Patrons. Journal of Studies on Alcohol 2003; 64:765-772.

28. Graham K, Osgood DW, Zibrowski E, Purcell J, Gliksman L, Leonard K, Pernanen K, Saltz RF, Toomey TL. The effect of the Safer Bars programme on physical aggression in bars: results of a randomized controlled trial. Drug and Alcohol Review 2004; 23:31-41.

29. Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35(extra issue):80-94.

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5 Comments:

  • At December 12, 2007 at 7:56 AM , Blogger Victoria said...

    I like how you pointed out the different factors that go into the aggression level in bars (the crowding, noise, etc). My question is - if 65% of fights in bars are alcohol-related, what are the other 35% about? (sober people that fight for various reasons?)

     
  • At December 14, 2007 at 9:47 AM , Anonymous Deinera said...

    Yes, but I think that's something that hasn't really been explored (as much as alcohol-related aggression that is). The literature on bar-violence itself is quite limited...though to deal with fundamental causes of bar-related violence, reasons behind why bar violence occurs need to be looked at more. Some articles suggest fighting has to do with location, peer groups, environment of the bar etc, but none of the articles I read specifically asked why those who were not under the influence of alcohol fought in a bar versus elsewhere (or if they were more aggressive in bars than they were elsewhere), or if the triggers for alcohol and non-alcohol related bar violence differ...but it would be interesting to find out!

     
  • At December 14, 2007 at 12:26 PM , Blogger Read said...

    You found a great intervention that's so out of touch with reality. Do you think that the Cage Your Rage creators have every had even one drink of alcohol before?! Or been to a bar?!

     
  • At December 15, 2007 at 8:51 AM , Anonymous Deinera said...

    I thought the same thing! Based on the intervention, I would it's doubtful :)

     
  • At December 15, 2007 at 8:51 AM , Anonymous Deinera said...

    That is, say it's doubtful!

     

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