The National Anti-Drug Media Campaign against marijuana use: Poor Understanding of Adolescents leads to Campaign Failure –Marsha Kocherla

1n 1998 The Office of National Drug Control Policy (ONDCP) launched the National Youth Anti-Drug Media Campaign in response to an upsurge of recreational drug use among adolescents. Drug use had been declining since the late 1970’s but rose sharply in the 1990’s from 10 percent in 1991 to 22 percent in 1998. The ONDCP proposed the 5-year campaign to Congress in 1997 and received $1 billion in federal support. This is the largest financial commitment that the federal government has ever made to an anti-drug media campaign (1).
Following the lead of other programs designed to promote youth health, the ONDCP relied on The Social Cognitive Theory of behavior to design the National Youth Anti-Drug Media Campaign. Social Cognitive Theory emphasizes the dynamic interaction of social-environmental factors, behavioral factors and personal factors in determining human behavior. Social-environmental factors are aspects of the environment that promote, permit, or discourage engagement in a particular behavior. These factors include influential role models (peers, teachers, etc.), situational contexts, social norms for behavior, and social support from friends and family. Behavioral factors are preexisting factors that affect behavior directly; these include extant behavior patterns, behavioral intentions, behavioral abilities, and coping skills. Personal factors are individual dispositions and cognitions that influence the likelihood of a person’s engagement in a particular behavior. These factors include level of knowledge about the behavior, personal attitudes towards the behavior, values, beliefs, and self-efficacy, or the belief in one’s own ability to carry out a certain behavior (2). Personal factors also include such complex abilities as the ability to determine the underlying meanings of behavior, the ability to foresee the outcomes of behavior, the ability to learn by observing others, the ability to self-regulate and self-determine behavior, and the ability to reflect on and analyze behavior (1). Social Cognitive Theory, by addressing the influence of multiple factors on behavior, recognizes the multi-dimensionality of behavior. The National Youth Anti-Drug Campaign however failed to understand the complexity of adolescents, and thus was unable to impact its target audience in any significant way.
The campaign relies on appeals to emotion rather than to reason
One of the main objectives of the National Youth Anti-Drug Media Campaign is to enhance perceptions that using certain drugs will lead to negative social consequences. The campaign takes the stance that smoking marijuana makes someone more likely to disappoint peers and family (1). The “Swim Meet” advertisement exemplifies an attempt to convey this message. The piece begins at a swim meet with the sound of a whistle being blown. We see three lanes (5, 4, and 3 from left to right) and three women’s swim teams. An announcer on a megaphone introduces the event: “JV Women’s 200 meter medley relay.” The teams in lanes 3 and 5 each have a swimmer on the diving board and three swimmers lined up behind her. There are only three members in lane 4, however, and they are standing around the diving board, scanning anxiously for the starting swimmer, who is conspicuously absent. The announcer notices and asks over the megaphone, “Do we have a swimmer for lane 4?” There is no answer, only the sound of a cough from the audience and people shifting in their seats. The announcer repeats the question, a brief silence follows, and the narrator begins the message of the ad: “Just tell your teammates you missed the race because you were getting stoned…” The announcer calls, “swimmers take your marks,” and the swimmers in lanes 5 and 3 poise themselves to dive into the water; the swimmers in lane 4 stand helplessly. “They’ll understand,” the narrator finishes. The viewer hears the starting horn as the words, “Responsibility; your anti-drug” flash across the screen (3).
This advertisement is ineffective because the behavior being negatively portrayed is not marijuana smoking but irresponsibility, which is assumed to be a result of marijuana smoking. The teammates’ disappointment at being unable to participate in the swim meet is the major appeal to pathos in this advertisement. The viewer is supposed to feel sympathy for the swimmers and he does. But the advertisement seems to expect that this sympathy for the swimmers will somehow translate into disapproval of marijuana smoking. Marijuana smoking is not the only behavior that could result in the situation portrayed by the advertisement and the viewers know that. Youth are not blindly led and are not easily persuaded; they demonstrate a complex capability to filter, interpret, and if necessary, reject messages presented by the media, and are very capable of separating emotional appeals from persuasive fact. While viewers may have an emotional response to the immediate stimulus of the advertisement, this will not translate into a long-term change in perception about drug-use (4).

The campaign fails to understand its target demographic

The members of the National Youth Anti Drug Campaign’s target demographic fall into one of two categories: late childhood, the period from age 9 to 12, or adolescence, the period from age 13 to 18. These periods of development are marked by dramatic cognitive changes, which include the development of the ability to reason logically (ages 7 to 11) and the ability to reason abstractly (ages 12 to 18). In addition, during these periods thought is becoming less egocentric and children are beginning to place more and more importance on developing close social relationships (5, 6). It is important for a media campaign targeting youth to understand the importance of social relationships in the lives of adolescents.
The swimmers in the advertisement, being normal adolescents, would probably not be as quick to judge or to excommunicate their missing teammate as the advertisement suggests. They would also be unlikely to place a swim meet as being more important than their teammate, and their love of swimming or enjoyment of the team would probably not be diminished by the day’s experience. Reaping the benefits of youth sports does not require intense competition or especial athletic prowess; it only requires participation. The major benefit of participating in youth sports is the social acceptance and self-esteem gained by being a member of a team (7). Excellence and victory are smaller components of organized sports that can only be reached once mutual respect, affability, and positivity exist within the team (8).
The outcome of drug use as portrayed by the campaign is not perceived as negative
“Supermarket,” another Anti-Drug advertisement, begins with an older teenager standing in a darkened super-market parking lot, shifting his weight and trying to keep warm, while inviting the stares of passers-by. He is obviously waiting for someone, a younger teenager, named Anthony, who appears from the supermarket after saying goodnight to the manager. Upon seeing Anthony, the older teen crosses the parking lot and calls his name. Anthony looks pleasantly surprised and asks the older teen what he is doing there. The older teen says that he is waiting for Anthony and Anthony asks, “What’s up?” The older teen hesitates, clearly uncertain of how to begin. The narrator speaks. “It takes a lot of guts to talk to your friends about their problems with drugs or drinking but it could make all the difference.” The screen fades and the message of the ad is displayed: “Courage: the anti-drug” (9).
This advertisement does not seem to be aimed at the drug-user but at the friends of drug-users, whom the advertisement encourages to dissuade their friends from using drugs. The advertisement is based on several assumptions, many of which are unfounded, and some of which are contrary to research findings. The advertisement assumes that there is a significant faction of teenagers in existence who have strong views against marijuana, but this is not the case. Social disapproval of marijuana smoking has decreased since the 1970’s, along with the perception of marijuana’s risk to health (10). The focus on marijuana in the media, rather than deterring marijuana use, has sent the message that marijuana use is common and widespread (11).
The advertisement also expects that the viewer will side with the older teenager, but by failing to develop the character, does not give the viewer a valid reason to do so. All that the viewer sees about the older teenager is that he is lurking in a darkened parking lot, visiting his friend at work, unannounced, and bringing up a subject that may cause conflict in the friendship. The soundness of the older teenager’s argument against drugs and proof of his courageous character are not presented, and this lack of evidence confers the older teenager no advantage in winning the viewer’s sympathy (3). Anthony, the drug-user in this piece, on the contrary, presents quite a positive image.
By being gainfully employed, Anthony is not only enriching his own life, but is contributing to the economy and to the community (12). Working late nights at a supermarket, Anthony seems disciplined, and his affability with the manager suggests that he is a good worker. Moreover, Anthony, although tired from a day of work, is still polite enough to spare time for a friend who wants to talk. The viewer sees no negative effects of drug use on Anthony’s life; rather, Anthony seems financially stable and socially adept, which gives the viewer little reason to think him in distress or in need of an intervention. Anthony’s array of competencies makes him more likely to be regarded as popular, a distinction that would give him greater influence over peers than the average teenager (13).

Conclusion

In conclusion, the campaign fails primarily because it misunderstands its target audience. The ONDCP fails to appreciate the complexity of adolescent thinking; by focusing on evoking emotion from the viewer rather than persuading him with facts, the campaign fails to induce a long term change in perception. Furthermore, the campaign overlooks monumental importance of peer relationships in the adolescent life. Finally, messages based on assumptions that are often contradictory to research undermine message credibility and dilute the efficacy of the campaign.
The National Youth Anti-Drug Campaign is unprecedented in breadth and in the financial support it garnered. However, due to ineffective strategies, the campaign proved disappointing (14). This not only implies a waste of resources but also the unchecked exacerbation of the drug problem in America.

REFERENCES
1. Kedler, S.l. Planning and Initiation of the ONDCP National Youth Anti-Drug Media Campaign. Journal of Public Health Management Practice. 2000; 6:14-26.
2. Edberg, M. Essentials of Health Behavior. Sudsbury, MA: Jones and Bartlett Publishers,2007.
3. “Swimmeet” Anti-Drug Ads. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.whatsyourantidrug.com/ads.asp#
4. Katovich, M. Media Technologies, Images of Drugs, and an Evocative Telepresence. Qualitative Sociology. 1998; 21:277-297.
5. Dasen, P. Cross Cultural Piagetian Research: A Summary. Journal of Cross-Cultural Psychology. 1972; 3:23-40.
6. Erikson, E. Childhood and Society. New York, NY: Norton, 1950.
7. Seefeldt, V. Youth Sports in America: An Overview. PCPFS Research Digest. 11: 2-20.
8. Schewe, A. Find the right sports program for your kids. CNN, 2005
http://www.cnn.com/2005/EDUCATION/09/28/youth.sports/index.html
9. “Supermarket” Anti-Drug Ads. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.whatsyourantidrug.com/ads.asp#
10. Bachman, J. et al. Explaining Recent Increases in Students’ Marijuana Use: Impacts of Perceived Risks and Disapproval, 1976 through 1996. American Journal of Public Health 1998; 88: 887-892.
11. Leinwand, D. Anti-drug advertising campaign a failure, GAO report says. USA Today. 29 Aug. 2006; 3 Dec. 2007.
http://www.usatoday.com/news/washington/2006-08-28-anti-drug-ads_x.htm
12. International Labour Office. Youth Employment: A Global Goal, a National Challenge. Geneva, Switzerland: International Labour Office, 2005.
13. Newcomb, AF. Children’s peer relations: a meta-analytic review of popular, rejected, neglected, controversial, and average sociometric status. Psychological Bulletin. 1993; 113: 99-128.
14. National Institute on Drug Abuse. Evaluation of the Office on National Drug Control Policy (ONDCP) National Youth Anti-Drug Media Campaign. Washington, DC: National Institute on Drug Abuse, 2004.

Anti Drug and Marijuana Ad Campaigns Fail To Dissuade Youths From Smoking – Aaron Manders

Anti marijuana advertisement campaigns have failed to effectively curtail marijuana use amongst adolescents. A report by Westat, Inc. written by Orwin, et al., showed that increased exposure to certain anti marijuana advertisements has been linked to an increase in weakened anti drug norms among adolescents and the increased perception that their peers are using marijuana. Their latest report detailing the effectiveness of the largely anti marijuana anti drug campaign (1998-2004) sponsored by the National Youth Anti-Drug Media Campaign (NYADMC) and the National Institute on Drug Abuse (NIDA) showed no attributable benefit to the campaign. Furthermore, higher exposure to the anti marijuana portion of the campaign was correlated with an increased smoking initiation and lacked a correlation between increased exposure and decreased use or quitting (1).
Although the federal government failed to create a campaign that significantly decreased marijuana usage, smaller scale campaigns have shown positive results in adolescent populations (2,3). Thus, the failure of the campaigns sponsored by NIDA and NYADMC are inexcusable. National campaigns to lower adolescent use of marijuana have been largely ineffective because they either focus on fear or absurd over exaggeration. In addition, the campaigns failed to consult and apply adequate research, did not appeal to teenage sensibilities, failed to apply relevant social science theories, nor are they congruent with messages portrayed in mass media or state government legislation.
In Focus: Recent Anti Marijuana Advertising
The following will focus on recent marijuana campaigns, specifically, the advertisements that were created during the Bush presidency. Before President Bush appointed John Walters anti drug messages had focused on a variety of drugs, but once Walters was appointed he decided to focus on marijuana use. Ben Wallace-Wells reported that Walters dismissed scientific data that failed to find a significant connection between marijuana use and later use of other illicit drugs. Walters’ tenure as drug czar led to the creation of ads with a variety of approaches (4). Some ads are more effective than others, but according to Westat, Inc’s data have culminated in an overall failure (1).
In the past the ad campaigns have been ineffective because they relied primarily on scare tactics, focused on negative consequences, and used obvious exaggeration rather than focusing on issues important to adolescents. Ad campaigns focused on fear and negative consequences have been shown to often be counter productive (5). Furthermore, the research that provided the basis for recent anti marijuana ad campaigns was focused on self reporting by adolescents. Self reporting of substance abuse may be an inaccurate representation of the actual actions of teens (6,7). In addition, influences such as peer pressure, a desire to conform, and cynicism of the messages of adults may further distort self reported analysis (8). Brandweek conducted a series of focus groups in order to discover adolescents’ feelings on anti drug messages directed at their demographic. The adolescents reported that they wished for life like scenarios that were plausible in their own lives. The adolescents also expressed a desire for truth in advertisements. Brandweek’s focus groups, as well as National Research Council reports point to the reasons why the campaigns have failed (9,10). However, nine years after publication and one campaign failure later, the Above the Influence campaign is still putting forth comical and unrealistic advertisements to decrease adolescent marijuana use (1,11).
A Sample of the Advertisements
Three ads highlight approaches that have been continually unsuccessful. First, the “Stoners in the Mist” series available at AboveTheInfluence.com documents a jungle survey team researching the native habits of the not so elusive “stoner.” The series of public service announcements are outlandish, silly, unlike anything teens truly encounter, provide fodder for ridicule form media sources and potential contempt from their target demographic. Another ad shows a talking dog telling a high teen that he misses her as a friend. The talking dog insinuates that marijuana will make you hallucinate, which adolescent’s will recognize as untrue, deceptive, and consequently reject the desired premise of the ad that smoking marijuana will push you out of your peer group. Finally, a girl walks out of her house to find that pictures of her doing something wild, obscene, or embarrassing have flooded the internet and have subsequently ruined her life - because she “got high.” The ad attempts to use the popularity of social networking sites and the ability to spread data quickly to try to scare teens out of using marijuana. Once again, the claims are sensationalized and there is no mention of alcohol consumption which lowers inhibitions (11). Also, the plot is too simple to not draw the cynicism of the target demographic. In addition, the ads are at odds with other ads in the campaign which note that nothing bad is going to happen if you smoke marijuana other than wasting your life on a couch (12). The incongruent advertisements highlight the mixed messages which are extremely detrimental to the effectiveness of anti marijuana advertisement.
Mixed Messages
There are mixed messages between the federal government’s own advertisements, current laws regarding marijuana possession, and the message of the media (print, television, radio, movies and now the internet). The anti marijuana advertisements fail to consider the overwhelming and increasingly pervasive role of agenda theory in a web based culture. Agenda theory states that media outlets have a large portion of control over which messages will be related to the public and therefore largely influence which issues the public finds important (13). Increasingly, mainstream media outlets have aired programs challenging the government’s policy. Media sources such as ABC News, Salon, the Daily Show, Slate, the Washington Post, and the Huffington Post have all produced segments or articles that are contrary to the government’s anti marijuana agenda. The internet also provides adolescents with a portal to less mainstream media such as web logs and emergent web sites such as Digg, Reddit, and Plastic that provide a constant stream of messages often opposed to that which the federal government is trying to set forth. Furthermore, individual states and cities have proposed and passed legislation legalizing medical marijuana use as well as decriminalizing marijuana possession (14,15). The laws help increase confusion and distrust with the anti marijuana message from the federal government. With the increased importance pervasiveness of today’s varied media culture, pro or anti marijuana challenging messages can be easily spread through an adolescent’s social network.
Adolescents are subjected to a large amount and variety of messages every day. They are bombarded with advertisements and other social influences. The combination of media, rumors among social networks and peers, heavy emphasis on anti marijuana campaigns and severe penalties associated with marijuana may all push to internalize a message of mass marijuana use amongst teens when the numbers are not alarmingly high. Only 6.6% of 8th graders, 15.2% of 10th graders, and 19.8% of 12th graders surveyed by the NIDA had used marijuana in the past thirty days (16). Although communicative efforts have been shown effective at changing perceived norms, the advertisements perpetuate the norm of widespread marijuana use (17). For example, one Above the Influence ad depicts a teen driving around his high friends while informing the viewer how he’s still part of the group even though he does not smoke. The ad makes the point that remaining a vital member to your social group without smoking marijuana is possible. However, the ad fails because it perpetuates the perceived norm that smoking marijuana is the norm rather than the exception. Messages such as the one in the previous ad may become internalized. Internalization occurs when an idea, action, or norm is accepted and adopted by an individual. The internalization versus the absence of internalization, which Kelman referred to as compliance, is an important distinction. If a message is internalized the message need not be as strongly supported by an individuals referent group which includes peers, family, or significant others (18,19). For example, a perceived norm that is actually false may be perpetuated even though person’s social network does not support that norm (19). Perceived norms of high levels of marijuana use among the adolescent populations may be similarly perpetuated. The government has created advertisements that reinforce the perceived norm and help aid internalization of said norm. When the perceived norm of marijuana use is further reinforced by the messages of mass media the norm may become difficult to alter. Advertisements that reinforce a perceived norm is neither realistic nor beneficial to the goals of anti marijuana advertisements.
Thus far, the anti marijuana ad campaigns have failed to provide a consistent message that appeal to teens sensibilities and values that include the need to fit into social norms, conform to peer and social groups, and suspicion of adult messages. Studies have shown a significant link between exposure to illicit drug use in peer networks and use of illicit drugs (20). Yet, most ads fail to take exposure within peer groups into account. Certain ads have addressed the importance influence of social networks and social influences. One Above the Influence ad tried to address the issue of social networks and the influence of peers. The ad titled “S.L.O.M.” depicts a school which has a problem with kids sticking leaches on themselves as an analogy to marijuana use. The advertisement is meant to connect marijuana use with a completely absurd action, in addition to drawing on the adolescent’s desire to be an individual. However, the ad fails miserably in several ways. First, the ad affirms the perceived norm of widespread marijuana use. Secondly, the ad it misinterprets an adolescent’s want to be an individual in the context of his overall environment with an adolescent’s desire to be an individual while conforming to social norms within valued peer groups. Finally, the ad fails because it makes SLOMing look cool. The students SLOM in the bathrooms, hallways and even classrooms at school while befuddling and frustrating the adults which the adolescent’s so desire to rebel against. “S.L.O.M.” shows that you can be cool, attractive, fit in, and stick-it to the teachers by smoking marijuana.
Although the advertisement creators mistakenly portrayed marijuana use in a desirable light, they have advanced beyond focusing on negative consequences in ads. The “just say no” attitude is condescending to the perceived intricacies of an adolescent’s life (8,9). Past ads focused on the supposed horrors of marijuana use rather than relating to important factors in an adolescents life. Ads that tell adolescent’s that their marijuana habit is funding terrorism, or going to cause them to run over a little girl on a bicycle, or shoot their friend in the face in no way approach teens on their level.
In Summation: Failure and the Future
Anti marijuana advertisements aimed at adolescents must take into consideration a whole range of factors including peer networks, social norms, the media’s agenda, and adolescent’s perceived needs and desires. Addressing all of these issues simultaneously may be nearly impossible and fortunately for the public, but not for the NYADMC, the media’s agenda is largely out of their control. Unlike the Truth campaign which focused on rebelling against tobacco corporations while still showing the negative effects of cigarette smoke, anti marijuana advertisements lack the corroboration of overwhelming and consistent scientific data regarding the drug’s deleterious effects. However, the anti marijuana campaigns still have hope. Ads that focus on the important values of adolescent life – peer acceptance, social status, and conforming to social norms could be addressed more effectively. The Above the Influence campaign has shown promise and a cautiously favorable media reaction (21). However, many of the ads still sensationalize, and either do not address the core values of adolescents or do so in a manner that is comical to the point of satirizing itself (i.e. Stoners in the Mist). Although the advertisements have promise further research must be conducted in order to create cohesive messages that truly appeal to and effect the target adolescent demographic.
References
1. Westat, Inc. Evaluation of the National Youth Anti-Drug Media Campaign: 2004 Report of Findings, Executive Summary. Washington DC: Westate, Inc. 2006.
2. Grabmeier, J. New Anti-Drug Program Shows ‘Phenomenal Success’ by Focusing on Positives. Research Communications, OSU. http://researchnews.osu.edu/archive/antidrug.htm, 2006.
3. Palmgreen, et al., Television Campaigns and Adolescent Marijuana Use: Tests of Sensation Seeking Targeting. American Journal of Public Health. 2001; 91: 292–296.
4. Wallace-Wells, B. How America Lost the War on Drugs. In: Rolling Stone Magazine. Nov. 2007. http://www.rollingstone.com/news/story/17438347/how_america_lost_the_war_on_drugs
5. Varshavsky, T. Media Drug Prevention and Public Service Advertising: Evaluating The National Youth Anti-Drug Media Campaign. Tufts University, 2003.
6. Fan, et al., An Exploratory Study about Inaccuracy and Invalidity in Adolescent Self-Report Surveys. Field Methods. 2006; 18: 223-244 (2006)
7. Williams, R and Nowatzki, N. Validity of Adolescent Self-Report of Substance Use. Substance Use & Misuse. 2005; 299-311.
8. Hill, D. “Drug Money” Brandweek. 1998; 39: 20-27.
9. Desperately seeking solutions. Brandweek. 1998; 39: 29-32.
10. National Research Council. Policy on Illegal Drugs. What We Don’t Know Keeps Hurting Us. Committee on Data and Research for Policy on Illegal Drugs. Washington D.C.: National Academy Press, 2001.
11. Carleton College. Blood Alcohol Concentration. Northfield, MN. http://apps.carleton.edu/campus/wellness/info/alcohol/bac
12. National Institute on Drug Abuse. Pete’s Couch Advertisement. Washington, DC. http://uk.youtube.com/watch?v=2yfEvfJ9XAw
13. Carroll, C. and Combs, M. Agenda-setting Effects of Business News on the Public’s Images and Opinions about Major Corporations. Corporate Reputation Review. 2003; 6: 35-46.
14. Oregon Medical Marijuana Program (OMMP). Oregon, USA. http://www.oregon.gov/DHS/ph/ommp/, 2007.
15. O'Driscoll, P. Denver votes to legalize marijuana possession. USA Today; http://www.usatoday.com/news/nation/2005-11-03-pot_x.htm, 2005.
16. National Institute on Drug Abuse. NIDA InfoFacts. Washington, DC: National Institute on Drug Abuse, 2006.
17. Borsary, B., & Carey, K.B. Descriptive and injunctive norms in college drinking: A meta-analytic integration. Journal of Studies on Alcohol. 2003; 64: 331-341.
18. Kelman, H.C. Process of Opinion Change. Public Opinion Quarterly. 1961; 25: 57-78.
19. Lapinski, M., Rimal, R. An Explication of Social Norms. Communication Theory. 2005; 15: 127-147.
20. Kuntsche, El & Delgrande Jordan, M. Adolescent alcohol and cannabis use in relation to peer and school factors Results of multilevel analyses. Drug and Alcohol Dependence. 2006; 84: 167-174.
21. Stevenson, S. This Is Your Ass on Drugs: The New Case on Pot? It Makes You Lazy. http://www.slate.com/id/2150334/, 2006.

Talk about Addiction: Starting the Conversation or Enforcing Social Stigma? – Meghan Gavaghan

Addiction is a topic that is discussed often in public health. This disease engenders much research into prevention and treatment and its effects on the person, family, and community of those afflicted. In an effort to increase awareness of addiction as a disease, the Department of Public Health in Massachusetts, Bureau of Substance Abuse Services, is currently running public service radio announcements. These announcements serve to raise awareness of substance abuse and the inability of those addicted to get the services they need because of the social stigma attached to the condition. It is quite admirable for the Bureau of Substance Abuse Services to attempt to institute this kind of shift in public opinion that is certainly a barrier faced by people who need treatment to recover from dependency on drugs and alcohol. The method in which the Bureau goes about trying to shift the frame of the discussion of the treatment of substance dependency, however, ultimately is not effective in its implied goal of changing the social norms and stigmas associated with addiction and increasing the access to treatment. The Bureau’s apparent attempt at utilizing the Health Belief Model, its attempt at using communications theory, and its focus only on the social stigmas associated with addiction as the only barrier to accessing treatment all conspire to limit the campaigns overall effect on changing the social stigma associated with addiction and allowing more people to receive the treatment they desire.

The Talk About Addiction program instituted by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, is ambitious in its goals. In addition to running radio announcements on radio stations in the greater Boston area (see Appendix I), a website supports further learning and online tools to encourage the general public to think differently about addiction (1). The announcements provide dramatic examples of the labels and derogatory language that is often used to describe those with substance dependence. The intended audience appears to be those in the general public that have the belief that substance dependence is within the control of the user and is not a disease that can be treated like any other disease. This, however, is not clearly stated in the announcement, but rather is left up to the listener to interpret whether or not the announcement applies to them. In addition to personal accounts, the announcement discusses the current discrepancy between those who suffer from substance abuse and those that seek treatment. As stated in the announcements and cited on the website, “Only one out of ten Americans with drug and alcohol problems will get the help they need…” (1) and further states that, “…together, we can change this troubling statistic,” (1). The announcement further direct listeners to http://www.talkaboutaddiction.org in order to get more information on addiction and how to best help those who need treatment services. The website provides further personal accounts, information on prevention, information regarding stigma and how stigma affects the treatment of substance dependence, and treatment avenues for those dependent on substances. The website also pays particular attention to the role of health care providers and employers in recognizing addiction and treating those with dependence with dignity devoid of stigma.

There are some clear limitations to the program that should be discussed prior to delving further into the effect that this intervention has on achieving the goal of alleviating the social stigma associated with substance dependence. First, the radio announcement was broadcast on an AM radio news station (WBZ1030, Boston) which may limit the number and demographic of people who hear the announcement. Secondly, the announcement itself does little to inform the public on stigma and substance dependence and relies on the website to convey information. Lastly, access to the information within the Bureau’s website is incumbent upon one’s access to the internet. This could limit those who are in fact exposed to the information meant to change the social stigma. Looking beyond the surface level of the intervention, however, it appears as though the Bureau’s program could be effective in starting the conversation with regards to eliminating the stigma attached to substance dependence and allowing those who need treatment to get it. A closer look at the behavior models and theories that appear to be behind the development of the intervention, though, shows that the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, fails to effectively use social science theory to inform its intervention and therefore fails to shift the conversation away from stigmatization of those with substance dependence.

Before further discussing these limitations, it is important to discuss the link between stigma and substance dependence and the subsequent diminished access to treatment. Social stigma was characterized in an essay in the Lancet in February of 2006 by Link and Phelan as arising from 5 components. These components include labeling a person as different, linking that different person to undesirable characteristics, and then separating that different person from oneself, or stigmatizing. The different person then experiences discrimination based on those perceived undesirable characteristics, which is followed by a loss of social, cultural, economic, or political power (2). Further describing the effect of stigma, researchers have shown through a study of the societal framing of a diagnosis of mental illness or substance abuse that, “…both conditions were ranked as among the most stigmatized of 18 conditions, roughly on par with being ‘dirty and unkempt’ and having a ‘criminal record for burglary’,” (3). As a result of these stigmas, Link and Phelan go on to discuss the fact that the loss of power or control over one’s destiny puts the individual, who is already suffering from the disease of addiction, at a greater disadvantage in seeking redemptive treatment. Clearly, stigma of this magnitude that is perpetuated in society is a barrier to treatment faced by those with substance dependence and the Bureau of Substance Abuse Services was justified in attempting to alleviate this social burden on those persons seeking substance dependence treatment. While the Bureau of Substance Abuse Services was well-intentioned in attempting to change the conversation around substance dependence in the view of the general public, the intervention that they chose to implement failed to utilize or fully realize social science theory in a way that would effectively reach their target audience and assist those with substance dependence to truly get the help they need.

Health Belief Model – Informing or Detracting from Intervention?
In looking at the behavioral theory that this intervention could have been modeled after, it would appear that the designers were using the Health Belief Model to inform its creation. This is likely, as it is a widely utilized framework in many public health interventions (4). As discussed in Irwin Rosenstock’s summary article discussing the model, the Health Belief Model describes health behavior of the individual as a rational, balanced examination of the perceived susceptibility of a condition and the perceived seriousness of that condition weighed against the perceived benefits of and barriers to taking an action to prevent the condition (5). The inherent drawback of using the Health Belief Model is that the social aspect of decision making, in this example especially the stigma of substance dependence, is not taken into consideration during the process. As discussed by VanLandingham in his research on the influence of the Health Belief Model and the Theory of Reasoned Action on sexual practices among Northern Thai men, the author states that, “perhaps the most serious [problem] being its emphasis on the perceived costs and benefits of health behaviors and its relative neglect of personal and social factors,” (4). He goes on to say that, “One particular social factor that is difficult to incorporate into HBM…is peer group influence,” (4). In other words, an intervention developed using the Health Belief Model as a guide assumes that, when given the necessary information, a person will make a rational choice to follow that information regardless of the social pressures to do otherwise.

The disregard of the social pressures that frame the perceived costs and benefits of a health behavior is what ultimately detracts from the effectiveness of the Talk about Addiction campaign. The program is designed around the information provided to the listener of the radio announcement and the viewer of the website. It rests upon the assumption that once those listening to the announcement hear the personal struggles of those relaying their experiences of the stigma attached to substance dependence and those visiting the website see the statistics on addiction and how difficult addiction is to overcome (the perceived susceptibility and perceived severity aspects of the Health Belief Model) that they will rationally decide to treat addiction as a disease. This is in direct conflict with the widely accepted social norm that addiction is something that is completely in control of the individual and a weakness of the individual. The assumption that the testimonials will drastically change people’s opinions is misguided. One reason the testimonials may not have the desired effect is that the listener may not identify themselves as someone who agrees with the social norm that those with addictions are completely in control of their condition. The belief that substance dependence is not a treatable disease is most likely a subconscious belief that cannot be readily identified through self-reflection. Therefore, the listener may ignore the message that the radio announcement is trying to convey simply because they don’t realize that they harbor the belief that individuals are in control of their addictive tendencies. Also, the listener may not have any experience in dealing with a person with substance dependence and therefore may be unaware of the prejudices and preconceived notions that they harbor toward addicted individuals. The social norm, or the stigma associated with substance dependence, is the perceived barrier to the audience in making a change behavior and, considering the strength of stigma in society, is strong enough to dissuade any change in behavior on the part of the listener or viewer.

The Bureau of Substance Abuse Services could have improved upon the development of their intervention and reached a greater proportion of the general public by utilizing behavior theory that takes into account the importance of social norms and stigma in deciding behavior. One possible alternative would have been to consult the concept of diffusion of innovations theory to better influence a change in the social stigma associated with substance dependence. As discussed in the text by Edberg, this theory rests upon the idea that innovations, or new ideas and concepts, become part of society through a process of learning and adoption. The adoption of the new ideas begins with some smaller group of influential early adopters and then slowly diffuses throughout the society based on the success or acceptance of that new idea or concept. This theory originated in the development and acceptance of new technology, but can be applicable to social ideas as well (6). With this theory in mind, there is a body of evidence that suggests that health care providers would be an excellent group to focus on as early adopters of the idea that substance dependence is a disease that can be treated and should not be stigmatized as it currently is in society. Kay Redfield Jamison recently wrote an essay for the Lancet based on her own experience of mental health and substance dependence and the lack of clear understanding of these conditions as disease in the health care practitioner community. As she discussed when referring specifically to mental illness, “Unless we are willing to talk about how to deal with mental illness among professionals the problem is going to remain undiscussed, creating more fear and more stigmatization…Some of the stigma associated with mental illness exists because there has been so much bad teaching and inadequate treatment over the years,” (7). This idea is further supported by Bruce Link in a research study regarding the consequences of stigma on men with both mental illness and substance dependence. In his discussion of the findings of the study, he addresses the need to recognize the stigma that exists within the health care provider community that is a significant obstacle to treatment. He states, “Health care providers are therefore faced with the challenge of how to address stigma in its own right if they want to maximize the quality of life for those they treat and maintain the benefits of treatment beyond the short term,” (8). While focusing the intervention of the Bureau of Substance Abuse Services to a much more narrow audience of just health care providers, it could have more impact on actually changing public perception. Health care practitioners are respected members of society and if they begin the process of shifting the stigma of substance dependence, the general public is more likely to find it acceptable to treat substance dependence in that way, as well.

Radio – Effective Communication or Ineffective Source?
Despite the shortcomings of the Bureau of Substance Abuse Services apparent reliance on the Health Belief Model to inform the development of their intervention, the Bureau did make an excellent decision in attempting to use communications theory to enhance the effectiveness of the intervention. As discussed in the text by Edberg, communications theory, “aims to impact the agenda of what people are concerned about, in order to set the stage for or prompt action,” (6). By utilizing the media of radio to transmit the message of the intervention, the Bureau is attempting to set the agenda regarding the stigma associated to substance dependence and get the general public to think about the way we as a society treat those with dependence. On the surface, this seems like a very effective method of communication. In the radio announcements, very personal and impactful stories convey the damage that stigma can have on the treatment process for those dependent and those testimonies serve to try to persuade the general public to think differently about dependence.

It may be very difficult for the general public to identify with those in the radio announcement, however, because they are simply hearing a voice and not seeing the person. A major aspect of communications theory, as discussed by Edberg, is the encoding of information by the sender of the information (the Bureau) and the decoding of that information by the receiver (the general public). In the case of the Bureau’s message, the intent of the Bureau is that the general public will identify with the voices in the radio announcements and sympathize with the testimonials given with regards to the stigma associated with substance abuse. This emotional reaction to the radio announcement will encourage them to then shift the attitudes and stigmas they have associated with substance dependence. Edberg discusses the importance of choosing the proper channel within media to convey the message, as this is essential to the proper decoding of the message given by the Bureau. There is certainly a difference between reading a newspaper announcement, hearing a radio announcement, and viewing a television announcement. Edberg notes that, “selection of channels is important in health communications because, as we have noted, the channel itself is relevant to the meaning of the message and because some channels are better than others for reaching a particular group,” (6). The choice of the Bureau of Substance Abuse Services to utilize radio announcement rather that television limits the ability of the audience to decode, or interpret, the message that is being conveyed within the announcement.

The importance of the medium of communication is further supported in The Psychology of Radio, a book focused specifically on radio and its effect as a form of media. When discussing the limitations of radio, the author specifically mentions the lack of a visual element in diminishing the effectiveness of radio in advertising. He states, “Many products are much more significantly presented to the reader through photographs or artistic delineation than spoken word. No verbal portrait alone can do justice to stream-lined automobiles, to a pearl necklace, to the new styles of Paris…..pictorial reproduction of the product provides a valuable identifiability that radio cannot achieve,” (9). While this discussion focuses specifically on advertising of product, the general concept can certainly be applied to the intervention created by the Bureau of Substance Abuse Services. The Bureau, in trying to eliminate the stigma associated with substance abuse, is relying on the stories of those afflicted by stigma to persuade the general public to change their opinions, but this persuasive effect will not reach its full potential via spoken word without visual support. The Bureau could argue that the website associated with the intervention does provide that visual component, but those in the general public listening to the radio announcement may not be persuaded enough by the verbal testimonials to even go to the website to learn more. By focusing first on the auditory message of the testimonials and then the visual message conveyed on the website, the Bureau erroneously assumes that any use of communication theory is effective, rather than focusing on the most effective media, television or print advertising. The failure of the Bureau in capitalizing on a very persuasive media of print or television media diminishes its effectiveness in achieving the goal of alleviating the stigma of substance dependence and the inability of those afflicted to receive treatment.

Stigma – The Only Barrier to Treatment?
A final criticism of the intervention developed by the Bureau of Substance Abuse Services is its focus only on the effect of stigma on the inability of those suffering from substance dependence to receive treatment and the subsequent reliance on community or societal change to enhance the ability of those suffering from dependence to get the treatment needed. As discussed earlier, the effect of stigma is quite significant on the ability of those who are dependent to seek treatment, but it is certainly not the only barrier faced. The self-efficacy of the dependent person, the inability of the person to afford treatment programs, the lack of treatment facilities in one’s area, and the responsibilities of work and family are just a few other important aspects of the decision for a dependent person to seek treatment (10). The Bureau’s focus solely on the stigma associated with substance dependence diminishes its effectiveness in the goal of allowing those affected to receive treatment because stigma may not be the primary reason that a person does not seek formal treatment. By narrowing the focus of the intervention in this way, the Bureau further alienates those who have very different reasons for not seeking treatment. One particular group for which this is a relevant issue is women who are dependent on substances. Not only are treatment programs focused on women’s health limited in number, there are myriad individual and social characteristics that limit women’s ability to access treatment beyond stigma. Copeland notes that, “…the social costs of family disruption…inadequate training of health professionals to detect problem drinking among women, lack of women-only treatment services that also provided childcare, and lack of economic resources and insurance coverage,” (10) were all cited as reasons women did not seek formal treatment for their substance dependence. Additionally, many women are the primary caregivers for dependent children and those obligations were a major obstacle for seeking treatment for 28% of women who had dependent children at the time of their alcohol and other drug problems (10). Even after considering the difficulty in finding care for dependent children, women were also concerned that they could lose custody of their children altogether. The additional social stigma of having deficient maternal instincts furthered their addictive behaviors. The author concludes the article with a call for a holistic approach to the treatment of substance dependency, focusing not only on the stigma attached to substance dependence but also the financial cost of treatment and familial disruption that can affect a woman’s choice to seek treatment. By not addressing these other barriers to treatment, the Bureau of Substance Abuse Services fails to fully realize the goal of getting addicted individuals the treatment they need.

Future Interventions – Informed by the Past, Inclusive of All
In light of the three criticisms outlined above, further study of the intervention created by the Bureau of Substance Abuse Services is necessary in determining the actual effect of the radio announcements and website on changing the stigma associated with substance dependence. Without a qualitative analysis of the general public’s views on substance dependence before and after the intervention, the criticisms discussed in this critique may not be implemented in future intervention planning. The disregard of past successes and failures in the development of public health interventions leads to the repetition of previously unsuccessful initiatives (11). Perhaps if the lessons from past campaigns had been incorporated into the development of the intervention from the Bureau, we would have seen a more focused campaign. A more effective intervention would have featured a focused approach, perhaps on health care practitioners using the theory of diffusion of innovations to diffuse the concept of substance dependence and a disease from health care practitioners to the general public. It also would have included print and television announcements featuring the persons heard in the radio announcements to enhance the general public’s decoding, or understanding, of the impact of stigma on those suffering from substance dependence. Finally, the intervention would have addressed other barriers to seeking treatment, such as the cost of treatment and child care, those subpopulations such as women face in seeking treatment to enhance the goal of increasing the accessibility of treatment. Instead, the Bureau of Substance Abuse Services has produced an intervention that is limited in its ability to change the stigma associated with substance dependence and ultimately does not increase access to treatment. Future interventions developed by the Bureau of Substance Abuse Services should be informed by these research studies and the entire breadth of socials science to enhance their effectiveness in creating social change. The Bureau of Substance Abuse Services certainly begins the conversation regarding the stigma associated with substance abuse, but the intervention does not achieve its ultimate goal of getting the substance-abusing population the treatment that they need.

APPENDIX I.
In order to further understand the method of intervention used by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services, I have transcribed the three different radio announcements. You can also hear audio of the radio announcements at http://www.talkaboutaddiction.org/listen/. The first example utilizes many different voices to convey the message, while the other two examples utilize one person conveying their own life experience.

Dreams
“When you were young, did you dream about being addicted? Did you dream about having a problem with alcohol? With tobacco? With drugs? With gambling? People who struggle with addiction didn’t have that dream either. The truth is, no one chooses to be addicted because addiction is a disease, a disease that can be treated like any other and when treatment works, people do recover. Families recover. Communities recover. We need to start talking, talking about why we make people who struggle with addiction feel so ashamed. Talking about why only one out of ten Americans with drug and alcohol problems will get the help they need. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

Hope
“If your mom was addicted to cocaine, to crystal meth, to marijuana, would you call her a junkie? A burnout? A pothead? I am a mother, a mother of five, and I struggled with addiction for many years. I was called all those names and more and, after a while, I believed I was that junkie, that burnout, that pothead. I believed there was no hope for me. But there was hope because addiction is a disease, a disease that can be treated. And with support and treatment, it’s possible for people, families and communities to recover. I know. I’m one of those people. Only one out of ten Americans with drug and alcohol problems will get the help they need. Together, we can change this troubling statistic. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

Pain
“A drunk? A degenerate? A loser? It’s what people used to call me. People like my boss, people like my wife. After a while, I believed them and I would drink more to mask the pain. They thought I could stop on my own, that it was a matter of willpower, but addiction isn’t a choice. It’s a disease, a disease that can be treated just like any other and people do recover, families recover, communities recover. I know. I’m one of those people. Only one out of ten Americans with drug and alcohol problems will get the help they need. Together, we can change this troubling statistic. Let’s start the dialogue. Learn more about how addictions affect all our lives. Visit http://www.talkaboutaddiction.org sponsored by the Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Start the dialogue. Visit http://www.talkaboutaddiction.org.”

REFERENCES
1. Massachusetts Department of Public Health, Bureau of Substance Abuse Services. Talk about Addiction. Boston, MA: Massachusetts Department of Public Health. http://www.talkaboutaddiction.org
2. Link, Bruce G. et al. Stigma and its Public Health Implications. Lancet, 11 February 2006; 367: 528-529.
3. Room, Rebecca. Taking Account of Cultural and Societal Influences on Substance Use Diagnoses and Criteria. Addiction, 2006; 101 (Suppl. 1): 31-39.
4. Vanlandingham, Mark J. Two Views of Risky Sexual Practices Among Northern Thai Males: The Health Belief Model and the Theory of Reasoned Action. Journal of Health and Social Behavior, June 2005; 36 (2): 195-212.
5. Rosenstock, Irwin M. Historical Origins of the Health Belief Model. Health Education Monographs, Winter 1974; 2 (4): 328-335.
6. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers. 2007.
7. Jamison, Kay Redfield. The Many Stigmas of Mental Illness. Lancet, 11 February 2006; 367: 533-534.
8. Link, Bruce G. On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse. Journal of Health and Social Behavior, June 1997; 38 (2): 177-190.
9. Cantril, Hadley. The Psychology of Radio. New York, NY: Harper & Brothers. 1935.
10. Copeland, Jan. A Qualitative Study of the Barriers to Formal Treatment Among Women Who Self-Managed Change in Addictive Behaviours. Journal of Substance Abuse Treatment, 1997; 14 (2): 183-190.
11. Hallfours, Denise. Fighting Back Against Substance Abuse: Are Community Coalitions Winning? American Journal of Preventative Medicine, 2002; 23 (4): 237-245.

The National Youth Anti-Drug Media Campaign: Failure to Change Drug Attitudes and Use- Renata Koziol

The Office of the National Drug Control Policy created the National Anti-Drug Youth Media Campaign in 1998 as a communications and media-based intervention to prevent and reduce youth drug use. The target audience includes youth ages 9-18, with specific focus on middle-school adolescents. The campaign includes many media outlets, such as advertising on television, radio, and in print, partnerships with other well-known organizations, and interactive websites containing information for teens and their parents (1). The Anti-Drug Media campaign utilizes television commercials and its many Internet websites to positively influence and educate the nation’s youth against illicit drugs. A specific campaign program is the Marijuana Initiative, which provides anti-marijuana education and advertising. The objectives of this initiative include educating youth to reject marijuana and preventing or diminishing marijuana use by teens. This initiative utilizes “Negative Consequences” commercials; targeted mostly toward 14-16 year olds, these ads display strongly negative outcomes which can occur as a result of marijuana use (1). Westat, a health survey research company, conducted a study through June 2004 to evaluate the effectiveness of the Campaign on changing substance use, perceptions, and intentions among adolescents. The evaluation found that the Media Campaign may have had unfavorable effects, including increasing teens’ perceptions of marijuana use among their peers, causing weaker anti-drug norms, and resulting in high rates of initiation in teens who were exposed to the Campaign (2). The Youth Anti-Drug Media Campaign failed in achieving its goals because it relies on aspects of the Health Belief Model and fails to utilize social and behavioral science theories such as Social Expectations Theory in creating its intervention methods.

Unrealistic Commercials
The National Youth Anti-Drug Media Campaign’s anti-marijuana ads failed because they did not consider teenagers’ reactions to ads that are unrealistic, subject to mockery, and attack marijuana users directly. Some television ads place blame on the drug user, trying to make them feel guilty for their actions, and by using a moralistic approach, create an opportunity for teenage rebellion. For example, one ad entitled “Dog,” depicts a dog talking to his teenage owner. He tells her that her actions while she is under the influence of marijuana are inappropriate and that she becomes someone he no longer recognizes as his former friend (3). One reason this commercial is ineffective is because it chooses an unrealistic situation containing a talking dog. As a result of its content, this commercial can be subject to mockery, which can negatively affect its intended anti-drug message. Furthermore, the purpose of the ad is to make marijuana users feel guilty. This tactic can have an undesirable effect on teens who already use marijuana. For instance, teens might believe that the campaign is directly attacking their personal characteristics and behaviors, leading them to ignore the commercials and continue using marijuana. Also, targeting teens with feelings of guilt can have separate, undesirable issues regarding self-esteem, which is already a major concern of teens during adolescence. As a result of these aspects of the commercials, teens may be more likely to rebel against these condescending types of ads and continue to use marijuana, despite their exposure to the anti-marijuana ads.

Teenage Rebellion Against Authority
A fundamental characteristic of teenagers is rebelling against authority and social controls which are meant to compel individuals to conformity (4). According to the Reactants Theory, developed within social psychology, a motivational and psychological state of resistance is activated when personal freedoms are being threatened or eliminated. This state of reactance can cause persons to adopt or strengthen an attitude that is contrary to what was originally intended (5). This theory comes into play strongly during the teenage years, during which parents and society attempt to impose restrictions on teens’ behaviors, mostly for their health and safety. Hence, the National Youth Media Anti-Drug Campaign’s commercials, which threaten teenagers’ sense of freedom, play directly into teenagers’ desire to rebel and thus prevent effective anti-drug messages from being perceived. Teens who view the commercials are no less likely to change their marijuana habits or begin smoking in the first place (2).
In contrast, “truth,” the anti-tobacco campaign, uses teen rebellion to its advantage. The truth campaign ads display tobacco companies and their deception in gaining new, young consumers for their deadly product. Teens viewing these ads perceive the authority of Big Tobacco companies, and focus their rebellion against these companies, refusing to be pawns in this corporate game by limiting or avoiding cigarette use. Because these ads give youth the facts about tobacco smoking, rather than preaching to them about the harms, teens respond to these commercials favorably (6, 7). The “truth” campaign and its advertisements have been shown to be significantly effective in reducing teenage smoking, decreasing teen experimentation with cigarette use and decreasing intentions to begin smoking (6).

Efficacy of Youth Marketing
Furthermore, the “truth” campaign has been effective because of its basis for its intervention methods, mainly, youth marketing. The truth campaign began with collaboration between the advertising company in charge of the campaign and Florida state teens. The teens were able to voice their views and opinions on tobacco perceptions, use, and teenage behaviors, characteristics, and perception. Because of direct input from the target audience before ads were designed, the advertising company was able to analyze teenage views and create ads which would be effective because they resound with and appeal to the target audience (8). On the contrary, the anti-marijuana campaign design has not included input from its target audience, teens and preteens ages 9-18 (1). This has resulted in the lack of ability of teens to identify with the commercials and have positive perceptions of the message upon watching the commercials. One particular study conducted by researchers at Texas State University, in which teenage and young adult subjects viewed both anti-tobacco and anti-marijuana ads and then provided their written comments about them, found that anti-marijuana commercials resulted in similar rates of unfavorable and favorable comments, while anti-tobacco ads resulted overwhelmingly in favorable comments (7). Furthermore, anti-marijuana ads resulted in significantly less positive responses than did anti-tobacco ads. Thus, this study shows that anti-marijuana ads have failed in their objectives to produce favorable anti-marijuana responses among teens in order to counter and reduce marijuana use.

Social Norms
Additionally, the anti-marijuana ads were unsuccessful because they failed to take into account social norms and cultural influences surrounding marijuana use. Teenage group norms and peer influence have been shown to play large roles in substance use patterns among adolescents (9, 10). Adolescents identify with single or multiple crowds that can have significant influences on teens’ behaviors and perception. Perceived group norms are very important in influencing teenage health-related behaviors. Self-categorization theory suggests that individuals who identify with a particular group seek to strengthen their acceptance within and similarity to the group by behaving according to the perceived behavioral norms of the group (10). According to a study conducted by Verkooijen et al. in Denmark, teens who identified with groups such as pop, skate/hip-hop, techno and hippie had higher levels of marijuana and overall substance use (10). The study found that because these particular crowds are perceived to have higher substance use, teens who identify themselves with these groups had higher substance use than teens who identified with other groups, such as sporty, quiet, or religious. The results collected by the study showed a positive association between perceived marijuana use among a particular group and use of marijuana by those who identified with this group. The more a person perceived fellow members of the group as marijuana users, the more likely that he would also use marijuana (10). Thus, because many teens perceive marijuana use to be prevalent among their peers, they themselves are more likely to use marijuana or to intend to use it. The creators of the anti-marijuana ads did not take this fact into consideration; the ads were not effective in decreasing intention or use of marijuana among teens. Additionally, it has been shown that some of the anti-marijuana ads have actually increased exposure to marijuana information and increased teens perception of the prevalence of marijuana use among other teenagers, leading to greater interest in and intention to use marijuana.
Furthermore, overall societal norms and cultural influences surrounding marijuana use also affect adolescent perception of the anti-marijuana ads. In America, there is an ongoing campaign to legalize marijuana, for both medicinal and recreational purposes. California has legalized the use of marijuana for physician-recommended medicinal treatment of pain, as per Proposition 215 which took effect in November 1996 (11). Furthermore, there are many organizations, including the Marijuana Policy Project, that advocate the reform of current marijuana policies by legalizing and regulating the possession and sale of marijuana (12). Because teens are exposed to these conflicting influences and political issues surrounding marijuana use, they may not view marijuana as a harmful drug, or they may assume that marijuana use is prevalent or even acceptable (13, 14). Thus, they may be more inclined to try marijuana and then continue using it. Furthermore, ads which display marijuana as harmful and discourage its use may not have the intended effect on teenage perception, because teens have already been influenced by society, and are not seeking to change their strongly held views.

Perceived Risks Versus Perceived Benefits
Finally, the anti-marijuana ads failed because of their reliance on aspects of the Health Belief Model, which leads to the assumption that adolescents use cost-benefit analysis and rational decision-making to influence and determine their health-related behaviors. Thus, many anti-marijuana commercials display risks associated with marijuana use. According to the Health Belief Model, individuals use cost-benefit analysis when making health-related behavioral decisions. The model states that if perceived susceptibility or risk outweighs perceived benefits, the individual will not engage in the harmful behavior (15). However, much of teenage risk-taking behavior is spontaneous and impulsive, leaving little or no room for risk assessment (16). Teenagers do not always identify risks when performing behaviors, especially if adverse consequences of the behavior are not immediate, but gratification is. Research has also shown that even in cases where teens acknowledge high risks, the perceived benefits they identify carry more weight in their decision to perform the risky behavior (16). Thus, when planning on using marijuana, adolescents do not always evaluate risks associated with the behavior, some of which may not be direct or immediate.

Rational Thinking
Furthermore, the Health Belief Model is a “rational” model, assuming that individuals use rational thinking in their behaviors (15). However, many teenagers forgo rational thinking in determining their actions, particularly when influenced by their peers (16). Thus, the anti-marijuana commercials that rely on the Health Belief Model have not been successful because the Health Belief Model’s basic, traditional assumptions fail to account for adolescent decision making, and thus do not apply to all teens and their marijuana behaviors. These anti-marijuana ads do not have any significant direct influence on changing teens’ use of or perceptions relating to marijuana, according to the 2004 Evaluation of the National Youth Anti-Drug Media Campaign (2).

Failure to Achieve Goals and Ways to Improve
In summary, the National Youth Anti-Drug Campaign, and specifically the Marijuana Initiative, failed to achieve its goals of reducing and prevent marijuana use among America’s youth. An evaluation commissioned by the government found that although there was high exposure among youth to the media campaign, the campaign ads did not have favorable effects on teens’ anti-drug perceptions or initiation of marijuana use (2). The media campaign failed in part due to its lack of input from and connection with its adolescent audience. Furthermore, it relies on traditional public health models, such as the Health Belief Model, which do not always take into account aspects of the modern world with all of its outside influences and social contexts. Because the campaign failed to incorporate social, psychological, and environmental theories, it was not effective in producing positive changes. Recommendations for improvements within the Media Campaign include utilizing social and behavioral models based on groups, rather than individuals, to produce more effective ads, targeting teens more directly by creating commercials which have had teen input and feedback, and presenting facts and leaving the conclusion up to the viewer, rather then employing consequence-based messages.

REFERENCES
1. National Youth Anti-Drug Media Campaign. About the Campaign. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.mediacampaign.org/newsroom/factsheets/overview.html
2. Orwin R, Cadell D, Chu A, Kalton G, Maklan D, Morin C, Piesse A, Sridharan S, Steele D, Taylor K, Tracy E. Evaluation of the National Youth Anti-Drug Media Campaign: 2004 Report of Findings. Washington DC: Westat, 2006.
3. “Dog.” Television Ad Gallery. Washington, DC: National Youth Anti-Drug Media Campaign. http://www.mediacampaign.org/mg/television.html.
4. Eve, RA. A Study of the Efficacy and Interactions of Several Theories for Explaining Rebelliousness among High School Students. Journal of Criminal Law & Criminology 1978; 69(1):115-125.
5. Woller KMP, Buboltz, Jr WC, Loveland JM. Psychological reactance: examination across age, ethnicity, and gender. American Journal of Psychology 2007; 10:15.
6. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. 2000. Changes in Youth Cigarette Use and Intentions Following Implementation of a Tobacco Control Program. Journal of American Medical Association 2000; 284 (6): 723-728.
7. Ginsburg HJ, Czyzewska M. National Anti-Marijuana Ads Compared to Anti-Tobacco Ads: Difference between Immediate Favorable and Unfavorable Post-viewing Written Comments. North American Journal of Psychology 2005; 7(3): 367-378.
8. Hicks, JJ. The Strategy behind Florida’s “truth” Campaign. Tobacco Control 2001; 10:3-5.
9. Urberg KA, Luo Q, Pilgrim C, Degirmencioglu SM. A two-stage model of peer influence in adolescent substance use: individual and relationship-specific differences in susceptibility to influence. Addictive Behaviors 2003; 28 (7):1243-1243.
10. Verrkooijen KT, deVries NK, Nielsen GA. Youth Crowds and Substance Use: The Impact of Perceived Group Norm and Multiple Group Identification. Psychology of Addictive Behaviors 2007; 21(1):55-61.
11. National Organization for the Reform of Marijuana Laws (California Chapter). California NORML Patient's Guide to Prop 215. San Francisco, CA: National Organization for the Reform of Marijuana Laws. http://www.canorml.org/.
12. Marijuana Policy Project. Federal Action. Washington, DC: Marijuana Policy Project. http://www.mpp.org/.
13. San Dieguito Alliance for Drug Free Youth, “Don’t Underestimate Marijuana.” San Dieguito Alliance for Drug Free Youth. http://www.sandieguitoalliance.org/pdf/dont_underestimate_marijuana.pdf.
14. National Institute on Drug Abuse. Monitoring the Future: National Results on Adolescent Drug Use. Bethesda, MD: US Department of Health and Human Services, 2006.
15. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
16. Reyna VF, Farley F. Risk and Rationality in Adolescent Decision Making: Implications for Theory, Practice, and Public Policy. Psychological Science in the Public Interest 2006; 7 (1):1-44.

The Negative Effects of Criminalizing Mothers Who Use Illicit Drugs During Pregnancy – Marilyn M. St. Fleur

Over the last two decades several states have passed legislation to punish pregnant women for behavior that endangers their fetuses. The laws prosecute pregnant women who use drugs on the basis of child abuse, neglect, delivery and distribution of controlled substances, and involuntary manslaughter (6). Over 200 women in 34 states have been prosecuted in criminal courts for substance use during pregnancy. Many others have faced charges of child endangerment or neglect in civil proceedings, or have had their children removed from their care because they tested positive for drugs at the time of birth (6).

The behavior of pregnant women is closely monitored, largely because children are socially viewed as a vulnerable population. As a result the welfare of children is often widely protected through effective legislation. However, the current punitive approach that prosecutes pregnant women who use illicit drugs in an effort to protect the fetus is flawed. The new drug legislation fails to adequately solve this public health problem because it does not address the experiences of the mothers who use illicit drugs; the extreme punitive measures deter mothers from seeking proper healthcare, and it fails to protect from discriminatory application.

The Lives of Mothers

A weakness in the drug legislation is its inability to address the lives of pregnant mothers who use illicit drugs. For several of these mothers’ illicit drugs use is one of many factors present in their lives that can negatively impact their fetus. Studies have shown that up to half the women with drug and alcohol problems are depressed or have other diagnosed mental illnesses (1). Studies also found that women who use substances during pregnancy suffer higher rates of sexual abuse and domestic violence (1). Further studies demonstrate that without careful consideration of additional factors protection and incarceration of mothers can harm of the fetus prior to and post birth. As a result the individualistic approach that addresses drug use alone is simply a “band aid” on a large wound.

The approach of protecting the fetus but not the mother is flawed because the health of the mother has a direct effect on the fetus prior and post birth. In essence protecting one without the other has a high potential of leading to a chain of negative health outcomes. The focus of this intervention is on the fetus rather than the mother. The legislation is analyzing drug use independent of other factors that have large effects on the situation at hand. This approach focuses on the fetus, blames the mother, and has therefore become an intervention that can be harmful (11).

A situation that can parallel the harmful affects of this legislation in found in an individuals access to health care. Studies have proved the unhealthy behaviors and inadequate access to health care among people of low socioeconomic status account for only 10-16% of the socioeconomic differences in health (9). This is not to discredit the impact of addressing unhealthy behavior and access to health care, but to demonstrate the need to take other contributing life factors, like education level attainment and race/ethnicity, into account when creating policies. The legislation that seeks to protect the fetus of mothers who use drugs fails to take an adequate holistic approach and is therefore flawed and ineffective.

Fear - A Counteractive Tactic

Furthermore, the drug legislation prosecuting pregnant woman is a counteractive approach. Drug use and trafficking is part of a socially constructed “underground” silent economy (4). Women who are tested for drugs, for example during doctors’ visits, are often tested without their consent (1,6). In several states those that test positive are turned over to police, threatened with prosecution, forced into treatment, tried as criminals, and often sentenced to prison (1,6). These measures are likely to entice fear amongst pregnant woman who use illicit drugs and push them further underground. In essence the punitive measures close a line of communication between health care providers and mothers. Pregnant women who wish to avoid criminal prosecution may avoid seeking health care, which in turn can harm both the mother and the fetus.

Legislators must also be weary of the fact that very fearful mothers may even go to the extreme of terminating their pregnancy through self-inflicted harm to avoid punishment (6). For some very fearful or confused mothers it is the destructive nature of illicit drugs that motivates and supports their risky behavior -in addition to the addictive nature of the drugs - (12). Rather than scaring pregnant women away from health care, the legislation should be getting mothers who use drugs into health care and into treatment on a voluntary rather than punitive basis. Punishing women who have used drugs or alcohol during pregnancy by prosecuting them or incarcerating them may feed a sense of social retribution but does nothing to promote infant well-being (1,10). In efforts to protect the fetus these policies place pregnant women in prison exposing them to violence, infectious diseases, extreme stress, humiliation, stigma, and emotional distress (1,10) Nevertheless, legislators must understand that there is a psychological root as to why drug users choose to participate in such risky behavior, and it is important that the legislation passed not have counteractive effects that lead to further risky behavior.

Discriminatory Applications

Though the legislation seems broad and neutral it has been applied using discriminatory practices. Studies have shown that illicit drug laws of all kinds are used more often on racial minorities and the poor. Selectivity in drug screening is an example of how this is done. In South Carolina healthcare personnel look for indicators such as the absence of prenatal care as criteria to drug test mothers (1,6). The criteria targets low-income and minority populations because both groups have a greater tendency to not seek healthcare (5). Their lack of use of the health care system is due to a number of reasons, such as inadequate access to care, cost, quality, mistrust, religious beliefs and a lack of or restricted insurance policies(5). Discriminatory application of the legislation has lead to higher rates of prosecution and imprisonment in minority and poor communities. In Charleston, a city in South Carolina, forty-one mothers were arrested for illicit drug use during pregnancy (1). Forty of the forty-one mothers were black women (1). Nevertheless, when legislation enforcers use the number prenatal care visits as criteria to test mothers they place minority and poor mothers at a higher risk of punishment than other mothers.

In addition to screening, several states are enforcing the legislation only in public hospitals located in poor communities (1,6,3,7). The legislation in South Carolina – and other states – has not been equally applied to white and affluent neighborhoods. Physicians who found substances often associated with middle and upper class populations, such as methamphetamine and heroin, made referrals to social services, not to law enforcement (7). Evidence shows that criminal sanctions against pregnant women are applied unequally. Poor and minority women bear the brut of suspicion and prosecution. Punishing pregnant mothers who use illicit drugs during pregnancy by prosecuting or incarcerating them may seem lawfully right in protection of the fetus, but does nothing to promote infant well being (10). The legislation is flawed because it does not provide regulation or means to protect against discriminatory affects. Instead the legislation contributes to the social pressure and injustice faced by poor and minority groups.

Implications for Future Public Health Recommendations

Legislation that prosecutes drug users should incorporate a method to offer women help and control over their lives prior to taking any punitive measures. Once addicted to illicit drugs pregnant women face many barriers to getting help. Programs need to be put in place to help pregnant mothers who use illicit drugs understand the epidemic and provide them with ways of getting safe health care. A great deal can be done to safeguard maternal and child health, including providing universal access to high quality pre-and postnatal maternal care, mental health care, drug and alcohol treatment, health education, and healthy living environments in early childhood (1,5,6). Offering pregnant women medical, social, and educational services is a sustainable way of helping both the mother and the child.

Conclusion

The health of a woman is as important as the health of their fetus. Legislation must start supporting women, so that they, in turn, can be there for their children. Pregnant mothers, who turn to drugs as the result of their mental health or abusive and traumatic childhoods, need our compassion and access to treatment, not imprisonment (1). The new drug legislation fails to adequately solve this public health problem because it does not address the experiences of the mothers, instead it deter mothers from seeking proper healthcare, and does not protect from discriminatory application.

Several states are currently debating on whether women who abuse drugs during their pregnancies should be subject to criminal punishments. If the goal of such policies is to protect the health of future children, we as a society must question policies that drive underground women who need and may want treatment, and criminalize those brave enough to seek care (1). The power-coercive measure that states like South Carolina has taken to address the issue, is an ineffective approach. Criminalizing maternal drug use can lead to potentially tragic consequences for pregnant women, their fetuses, and their families. When pregnant women fear that they will be prosecuted for their drug use, they are less likely to seek prenatal care (1). It appears to drive drug-using women out of the health-care system and isolates them in their drug use rather than helping them have healthy pregnancies and healthy babies. Legislators must recognize this as truth and provide a means for pregnant woman who use illicit drugs to receive help for both themselves and their fetus.

References:

1. Armstrong E. Drug and Alcohol Use During Pregnancy: We Need To Protect, Not Punish, Women. Women’s Health Issues, Elsevier Inc. 2005; 15:45-47.

2. Billings Gazette. Meth-pregnancy bill criticized. Jofe Enterprises. http//www.billingsgazette.net/articles/2007/02/08/news/Wyoming.

3. CNN Health. Criminally Pregnant. http://archives.cnn.com/200/HEALTH/10/30/ethics.matters/index.html.

4. Destiny’s End. Socio-economic factors of the underground economy. http://www.wmich.edu/destinys-end/index.html

5. Edberg M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.

6. Gostin L. The Rights of Pregnant Women: The Supreme Court and Drug Testing. The Hastings Center Report 2001; 31:8-9.

7. Harris L. The Status of Pregnant Women and Fetuses in US Criminal Law. American Medical Association 2003;289:1697-1699.

8. Harris L. Rethinking Maternal-Fetal Conflict:Gender and Equality in Perinantal Ethics. The American College of Obstetricians and Gynecologist. Elseiver Science Inc. 2000;96:786-91.

9. Lu, N., Samuels M. et. al., Socioeconomic Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account for. Journal of Health Care for the Poor and Underserved 2004;15:618-630.

10. National Advocates for Pregnant Women. SC Supreme Court Hears Appeal: Don’t Punish Women for stillbirth. South Carolina. http//advocatesforpregnantwomen.org/issues/criminal_cases

11. Pearce, N. Traditional Epidemiology, Modern Epidemiology, and Public Health. American Journal of Public Health 1996; 86:678-683.

12. Siegel M. The importance of formative research in public health campaigns; an example from the area of HIV prevention among gay men (Appendix 3-A).Siegel M, doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Bartlett Publishers 2004; 66-69.

Dare To Think Beyond D.A.R.E.: A Critique Of The Drug Abuse Resistance Education Program – Alison Bayer

“Oh, I remember my D.A.R.E. officer…and singing a song at D.A.R.E. graduation! I don’t remember the words though. I just remember that we had to sing.” Mention the acronym D.A.R.E. to a group of college students or young adults and you will likely hear many reactions of this sort. Scattered memories of activities and events seem to be the largest effect of the D.A.R.E. program. This is a striking finding when one considers that D.A.R.E., the Drug Abuse Resistance Education program, is one of the most pervasive youth drug prevention program in America. Since its creation in 1983, the program has been implemented in seventy-five percent of U.S. school districts and has even been adopted in 43 other countries (1).

D.A.R.E. is a school-based health education program, which targets drug use by teaching youth about the consequences of substance abuse and providing skills needed to make smart decisions about drugs. The program is often noted for its use of community police officers as teachers. Specially trained officers visit classrooms and teach the D.A.R.E. curriculum to youth as young as kindergarteners and as old as high school students (1,2).

Many have questioned if D.A.R.E. is creating the right kind of memories. Is it leaving a lasting understanding of the harms and consequences of drug use? More importantly, is it creating an understanding that is translating into behavior change and a decline in drug use in America’s youth? Multiple evaluations have repeatedly found that the program’s effectiveness for reducing and preventing youth drug use is very limited if not insignificant (3). However, despite these findings, D.A.R.E. is continually used as the program of choice in communities across America. The question of why D.A.R.E. is so popular despite its well-known shortcomings is intriguing. Perhaps Americans wants to believe that D.A.R.E. will work. Maybe we are not ready to reject the program until we have come up with a better one. Regardless of why we continually choose the program, it is first critical to recognize why it does not work.

In order to successfully understand why D.A.R.E is falling short of its goals, it is important to look at the social and behavioral factors that influence drug use among youth and how the program accounts for or ignores these principles. Despite being one of the most commonly used and well- known youth drug prevention programs in America, D.A.R.E. is routinely found ineffective largely because it does not present accurate social norms, fails to look beyond in-school education as the appropriate mode of intervention, and does not account for differences in culture and environment which might affect drug use in youth.

Inaccurate Understanding of Social Norms

The D.A.R.E. program fails because it inaccurately presents social norms and consequently, often results in drug promotion rather than drug resistance. D.A.R.E. utilizes the Theory of Planned Behavior. In this theory, a person’s attitudes towards a behavior, their self-efficacy to performing the behavior, and their perception of the social norms of their communities or peer groups determine their behavioral intention, which leads to their behavior (4). D.A.R.E. targets attitudes, self-efficacy and social norms in order to influence intention and consequently change behavior. The program works to change attitudes about drug use by offering education about the harms of drugs and substance abuse. The program targets self-efficacy, a person’s belief in his or her ability to take action, by “teaching students good decision-making skills” and “showing students how to recognize and resist peer pressure” (2). However, D.A.R.E. does not successfully approach social norms and their influence on youth drug behavior.

D.A.R.E. fails because it inaccurately presents social norms. The program assumes that the drug use among youth is frequent and popular. The curriculum is designed to work around the belief that drug use is a normal part of youth culture and that young people frequently feel pressured to use drugs in order to appear normal and fit into their social groups. With this understanding of youth drug use, a key element in prevention is teaching young people refusal skills. Consequently, as D.A.R.E. focuses on teaching young people how to make smart and healthy decisions despite social pressures, they impart to youth the impression that their peers are using drugs and that drug use is socially normal. In reality, many of the kids who go through the D.A.R.E. program might not think that drug use is cool or common and might actually think that drug use is a poor choice made by only a small group of kids. They may think of drug use as the exception rather than the norm. However, when D.A.R.E. reveals to youth that drug use is popular, they may change their behavior for the worse. I hypothesize that D.A.R.E. lessons may actually make students increasingly curious about drugs and feel more pressure to try them as they attempt to adhere to the social values that they have learned from the program.

Peer pressure is indeed a concern when considering the use of drugs among youth. Researchers describe adolescence as a time of impressionability (5). As children grow older they make both well-contemplated and unconscious decisions about who they will become as adults. Rapid physical and cognitive changes are usually accompanied by an increased awareness of the opinions of others. Adolescents are severely conscious of their own behavior and personalities and are also very concerned with whether or not their peers like them (5). In this important developmental turning point, young people are greatly concerned with being a part of a group and not being regarded as different or as an outsider. Consequently, what a young person considers to be normal among his or her social group can be very influential to his or her behavior. However, though it is important to take this concern for social acceptance into account, it is crucial that program developers research and identify accurate social norms and values rather than assume that they know how a population perceives a behavior.

In reality, drug use may no longer be very popular among young people. Some researchers have found that adolescents believe that general attitudes of peers are against drug use (6). Jerald Bachman, Lloyd Johnston and Patrick O’Malley report that a decline in the acceptance of drugs has helped contribute to a drop in usage rates among young people, demonstrating that peer influence does not always result in poor behavior (7). Other investigators have hypothesized that peer pressure can influence drug resistance as well as drug use (6). In truth, social norms may be helping youth more than they are hurting them, but with its inaccurate perception of the norms, D.A.R.E. fails to utilize norms to their advantage. Adolescents are indeed very sensitive to their peers and seek social acceptance, and if D.A.R.E. tells young people that drug use is pervasive, adolescents may be more inclined to experiment with or begin using drugs than they were before their experience with the program.

Schools Are Not the Only Places Where Learning and Development Occur

The D.A.R.E. program fails because it relies upon school-based health education as the best method to provoke behavior change. The program fails to recognize that many other environments influence an adolescent’s decision to use drugs and that expanding or changing programs to target and utilize these environments might lead to a greater reduction of drug use. Research has shown that family and home life may be the first influences on youth to smoke, drink alcohol or use drugs (6). Children who are exposed to substance abuse at home are more likely to have their own issues with drug abuse and addiction as they get older (6). Likewise, young people who live in neighborhoods where they see or hear about drug use might be at greater risk of beginning substance use (6). Research has also shown that drug use is more likely to occur in neighborhoods with a low level of social capital, the interconnection between members of a society, or a decreased sense of community. In a neighborhood where people keep an eye out for each other’s children, substance abuse rates are often lower (5).

Despite the fact that researchers have identified multiple important realms of influence, D.A.R.E. approaches youth drug abuse primarily through schools. With the exception of a call for parental participation in some aspects of the program, D.A.R.E. does not address other environments. Consequently, the other environments that might be more likely to influence youth drug use are ignored, automatically decreasing the likelihood of D.A.R.E.’s success.

Schools in particular may not be an effective realm in which to address drug use because many adolescents who use drugs are rebellious, and are also likely to reject or dislike educational settings (8). Studies have found that youth who are at high risk of substance abuse have often dropped out of school, are frequent truants, or are at least a grade behind the average student in their age group (8). However, rather than taking these common characteristics of high risk youth into account, D.A.R.E. builds it program around using police officers as teachers in the classrooms. The use of officers adds an additional level of power to the already authoritative role of the teacher in the traditional school setting. While research has found that many students develop a good relationship with the officer teaching them, it also shows that this relationship depends on the environment that the youth were raised and live in (9). Adolescents who reject authority and display deviant behavior are unlikely to develop a good relationship with the officers. Consequently, those who most need intervention and lessons about substance abuse or who might benefit from an improved relationship with the normally feared police officers are not reached. Those who display or are likely to display deviant behavior are generally very resistant of others having control over them, so using authority figures to promote good behavior in these youth is a theoretically flawed method.

Schools and the use of authority figures might not be good methods to reach all youth. While school based health education can hold some value, other environments and communities that youth are involved in might reach young people better and need to be included or taken into account in the formation of programming.

One Size Does Not Fit All

The D.A.R.E. program is ineffective because it applies the same curriculum and method to youth of all backgrounds and in all environments. The program does not account for culture, likelihood of exposure to risk factors, social norms, and other factors which vary from environment to environment. Research has shown that people have unique experiences with substance use and have various reasons for becoming involved with drugs (8). When youth go through the D.A.R.E. program, they are most likely in different situations and have various understanding and experiences with drugs. Some may be frequent users with family members who do the same. Others may be very experienced and want to stop or are trying to quit using drugs. Some may be just starting experimentation, and others may know very little about drugs and have very little desire to experiment at all. However, the D.A.R.E. program approaches everyone as if they are on the same level of drug use and exposure. The messages and lessons provided are more effective in some groups than others, and D.A.R.E. does little to account for these differences in needed level and type of intervention. It is crucial to tailor a health program or intervention to the individual or group in order to account for important differences in experiences, levels of understanding, wants, and needs (10).

The D.A.R.E. program frequently uses one message to fit all groups. For example, a large part of the program’s curriculum is centered around the development of drug refusal skills. Officers provide young people with methods of rejecting the invitations and pressures of their drug using peers. In one of the lessons included on their website, D.A.R.E. instructs kids to “Stick with friends who are also against violence and drugs, and stay away from known trouble spots” (11). However, this task is probably much harder to do in the case where a young person has already begun to use drugs and has friends that frequently use drugs as well. These adolescents might have to overcome addiction as well as the fear or need to find a new social group on top of the task of refusing drugs. For these youth, turning away from drugs is not quite as easy as the D.A.R.E. slogan, “just say no” makes it seem. These youth would likely benefit from a different intervention that is more catered to their needs and situations such as information on drug abuse counseling options or even access to an open discussion forum where kids can discuss their feelings and concerns about drugs in a comfortable environment.

Other differences in background among young people can decrease the likelihood of success for the universal D.A.R.E. curriculum. In another online lesson on the program’s website, D.A.R.E. advises youth: “Don't use alcohol or other drugs, and stay away from places and people associated with them” (11). However, some youth live in neighborhoods where drug use is prevalent or even have parents who are drug users. Consequently, it is very difficult for these young people to simply stay away because for some that might entail moving to a new neighborhood or not associating with family members. The one-size-fits all curriculum of the D.A.R.E. program does not recognize the diversity of experience and background among the youth that it serves. Consequently, the program is very limited in its ability to successfully reach youth.

Conclusion

The D.A.R.E. program does not take into account important principles of social and behavioral sciences and consequently fails to meet its goals as a youth drug abuse prevention program. By assuming drug use is pervasive and popular among all young people, D.A.R.E. promotes inaccurate social norms which can result in increased perceptions of peer pressure and can actually elevate rates of drug use rather than reduce them. D.A.R.E. depends upon in- school health education as the best method to approach youth and does not consider or target other important environments that influence youth behavior and decision-making such as home, neighborhoods and peers. In consideration of the school-averse qualities often found in youth who use or are likely to begin using drugs, schools may be an especially ineffective environment to bring about behavior change in young people. D.A.R.E. also falls short of success because it fails to take into account personal, familial, and environmental factors that influence youth and drug use. Relying on one curriculum for all young people prevents the program from providing messages, lessons, information and resources that will be useful for youth with different levels of experience with drugs and varying exposures to risk factors of drug use.

The largest barrier for D.A.R.E. will be moving beyond the idea that it is a great program. D.A.R.E. remains the most popular youth drug program in America despite consistent findings that it does not succeed in reducing drug use among youth. The continued utilization and support of the program indicates that there must be some fixation with the idea that D.A.R.E. is really the best-designed anti-drug program around. This persistent reliance on a failed program might be a result of a failure or unwillingness to think beyond traditional individual health behavior change methods. With this limited mindset, the findings that D.A.R.E. does not work are either results of flaws in research design or due to a lack of a more innovative alternative program to replace D.A.R.E.. However, these are not reasons to continually invest time and money in a program that is not producing desirable results.

In order to succeed, D.A.R.E. needs to make substantial changes to its design and must begin to consider and incorporate the social structures and environments that influence drug use in youth. In order to include important influential factors, program developers need to do research and investigation into the needs of the youth they are attempting to reach and also need to recognize that one program may not fit all groups. By reflecting on the reasons why D.A.R.E. falls short, we can begin to move towards finding a program that leaves youth with more than scattered memories of singing songs and talking to police officers.

REFERENCES

1. D.A.R.E. America. About D.A.R.E.. Los Angeles, CA: D.A.R.E. America. http://www.dare.com/home/about_dare.asp.

2. D.A.R.E. America. What is D.A.R.E.? Los Angeles, CA: D.A.R.E. America. http://www.dare.com/home/Curriculum/what_is_DARE.asp.

3. Ennett S, Tobler N, Ringwalt C & Flewelling R. How Effective is Drug Abuse Resistance Education? A Meta-Analysis of Project DARE Outcome Evaluations. American Journal of Public Health 1994;84: 1394-1401.

4. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

5. Gordon S. Adolescent Drug Use: Trends In Abuse, Treatment and Prevention. Wernersville, PA: Caron Foundation, 2000.

6. Belcher H & Shinitzky H. Substance Abuse in Children: Predication, Protection, and Prevention. Archives of Pediatric & Adolescent Medicine 1998; 152: 952-960.

7. Bachman J, Johnston L & O’Malley P. Explaining the Recent Decline in Cocaine Use among Young Adults: Further Evidence that Perceived Risks and Disapproval Lead to Reduced Drug Use. Journal of Health and Social Behavior 1990; 31: 173-184.

8. Dryfoos, J. Adolescents at Risk: Shaping Programs to Fit the Need. The Journal of Negro Education 1996; 65: 5-18.

9. Hammond A, Sloboda Z, Tonkin P, Stephens R, Teasdale B, Grey S & Williams J. Do Adolescents Perceive Police Officers as Credible Instructors of Substance Abuse Prevention Programs? Health Education Research Advance Access 2007; October: 1-15.

10. White D & Pitts M. Educating Young People About Drugs: A Systematic Review. Addiction 1998; 93: 1475-1487.

11. D.A.R.E. America. The Official Web Site DARE.com. Los Angeles, CA: D.A.R.E. America. http://www.dare.com/kids/index_3.htm.