Drug Abuse Resistance Education (D.A.R.E.): An evaluation of program efficacy based on social science theory and available alternatives--Ashley Thomas

Introduction: The Drug Abuse Resistance Education (D.A.R.E.) Program

I remember when he first came into our classroom. He was very tall, neatly dressed, and very austere (I didn’t know that word at the time, but it perfectly encapsulates his demeanor). Then again, as a fifth-grader, everyone is very tall, anyone in uniform always appears neatly dressed, and all adults are austere. He quietly sat in the back of the room until our teacher, Mrs. English, introduced him. Despite how vivid all of his physical characteristics and mannerisms still are, I cannot remember his name, so for our purposes, we’ll refer to him as Officer Joe. Officer Joe was a trained officer of the Drug Abuse Resistance Education (D.A.R.E.) in-school program, and our classroom was his “beat” for the next few weeks.

Developed in 1983, D.A.R.E. is an in-school curriculum that addresses pressures placed on youth regarding drug use and violence (1). It has since expanded from its original home of Los Angeles to around 80% of United States school districts and 43 countries worldwide (1). Intrinsic to the program, making it unique among other in-school drug resistance education programs, is the incorporation of local law-enforcement personnel (2). Over a series of 16 weekly lessons, the officer charged with educating the students introduces facts about drug use (both underage and otherwise) and violence, while giving the students tools and strategies to employ later on should they be confronted with a, “…high-risk, low-gain choice…” (3)(4). At the program’s culmination, lesson 17, participating students will reflect upon what they have learned and what they hope to carry with them going forward.

The D.A.R.E. program was borne out of Nancy Reagan’s directive to children to, “Just say no!” to drugs and alcohol (5). Despite its current ubiquity, the D.A.R.E. program has been the target of many analyses and criticisms decrying its efficacy. In some cases, it achieves no measurable effect, certainly not enough to warrant the resources necessary for its implementation. While the program has, admirably, evolved significantly in response to these evidence based evaluations, understanding past failed strategies will be integral to creating new, more effective curricula.

In context, as of 2010 (most recently available data), drug and alcohol usage rates among teens and young adults climbed compared to past years. Among youth aged 12-17, the rate of illicit drug use was about 10% and about 7% reported currently using marijuana. The data is much starker when looking at alcohol: 29% of those surveyed reported being current users. Within this category, 25% of those aged 12-17 reported current use, and nearly 50% of those aged 18-20 reported current use in the past month (6). As was demonstrated not only by multiple meta-analyses, but also by the persistence of drug and alcohol use among minors, D.A.R.E. fails to resonate with the students for whom the program is tailored. This failure comes at high cost to the school, the state, and the federal government (7)(8).

This analysis will take a hard look at three specific aspects of the program model and question the social sciences theories from which those elements were derived. The model of the program is predicated on the assumption that, regardless of the situation or background of the student, he or she will be able to reason through a decision relating to drugs, alcohol, or violence. Many of the weaknesses of the earliest iterations of the program were a result of this intense focus on individual linear reasoned behavior. New curricula and lessons still fail to consider the environment in which the student is raised and the modeling that impacts their ultimate choice. Compounding this issue is the fundamental flaw of the program in addressing the normalizing of risky behavior in youth. While “peer pressure” is a focus of the program model, its interpretation within the model is dated and often not applicable to real-world circumstances. Finally, the program assumes that by injecting the students with a bolstered sense of self-esteem, environmental and situational influences will no longer be relevant. Unfortunately, youth and their social situations are much more complex than that.

I.               Criticism of the D.A.R.E. model

A.    Critique 1: What works for one should work for all

In its earliest versions, D.A.R.E. targeted fifth- and sixth-grade students. The goal was to intervene as early as possible to equip students as quickly as possible for any challenges they may face regarding drug or alcohol use, or violence. Even though the program was created for an extremely racially and socioeconomically diverse student population (9), the program takes a homogenous approach to all students, regardless of background.

Simply due to the sheer volume of students exposed to this program regularly, it is unrealistic to assume that all students receive the program in the same way. Based on the social learning theory, some behaviors have likely already been modeled and normalized in the home. While these are not the behaviors targeted by the program, the efficacy of the program is questionable if the students already have a mental construct of the impact of drugs and violence in the home. This mental construct can be healthy or dangerous, but the structure of the D.A.R.E. program does not account for either. The implicit conclusion that follows from the D.A.R.E. model is that any drug or alcohol use should be absolutely avoided. These rigid social norms will conflict with the modeling to which the student has already been exposed, and the desired effect of imparting a zero-tolerance mentality on the student is not just diluted, but also eventually lost (given the brief nature of the program).

In 2001, the National Highway Traffic Safety Administration (NHTSA) released a comprehensive set of “How To” guides around the topic of underage drinking prevention. In it, they mentioned that there are a number of risk factors that are reliable indicators of a student’s likelihood to abuse alcohol underage. These include the following: parental drug use, family structure and function problems, lack of commitment to school, anti-social behavior, and biological predisposition (10). With these in mind, the student who can most benefit from the message given by D.A.R.E. is least likely to engage with the program because she is not in school, nor would it be her first (or most formative) encounter with drug and alcohol use. Because of the program’s structure, however, these differential risks within the student population are masked and unattended. Even if family or friends have not exposed students to any sort of drug culture, they certainly encounter print, media, or Internet advertisements, and each student to varying degrees. Admittedly, singling out students who are at greater risk is not a favorable alternative, but the D.A.R.E. model presumes a homogeneity among students that does not, in fact, exist. If it did, the model would be singularly effective in any setting with any permutation of student representation, including those who’d already tried drugs or alcohol prior to participating in the program.

D.A.R.E.’s disregard for social and environmental pressures is indicative of its baseline belief in the capacity of the individual student to reasonably make a decision regardless of the situational constraints or past experiences. This stringent adherence to the individual level social science model (particularly the Theory of Planned Behavior) is effective in perpetuating the mission of the program but does not successfully equip students and youth with the tools necessary to confront complex situations involving friends and social pressures to conform.

B.    Critique 2: Fitting in is of no concern

In focusing so heavily on the individual agency of the student, the D.A.R.E. model does not effectively confront the realities of tenuous social situations, especially those encountered in groups. D.A.R.E. struggles to address peer pressure, but it does so in ways that neglect the very basic principles of herd behavior and social organization theory. Students are taught strategies and methods to, “Just say no!” but those strategies do not take into account the pressure of group behavior and perceived social roles.

The D.A.R.E curriculum prescribes very vague and general steps towards confronting peer pressure. In their model, they help students to identify characteristics of positive and healthy friendships and encourage them to build social and support networks buttressed by these relationships (3). The difficulty, however, is translating these skills to new environments with new and different potential friends and navigating potentially risky situations while in these novel surroundings.

The herd mentality theory asserts that individual choice is heavily, often imperceptibly, impacted by perceptions of behavior within the same peer group. In this scenario, a young underage student, most likely in high school or early college, attends a party where alcohol is being consumed. She leaves for the party armed with her fifth-grade D.A.R.E. training, but upon encountering a group of like individuals who are drinking, she is more likely to forget Officer Joe and instead join her peers. Thaler and Sunstein document behavioral changes like this not only in underage drinking, but in eating habits, voting patterns, and tax compliance (11). They point out that the notion of “acceptable” or “normal” behavior may, in fact, be based on false information, but the reality is that the group will behave in accordance with the prevailing assumptions. In this case, the prevailing assumption is, when you attend a party, you drink alcohol. What is at play here is an intense desire to conform. If the long-term consequences, however grave or benign, are not frighteningly obvious, conformity to immediate group behavior is inevitable and well documented. This is an insidious form of peer pressure for which the D.A.R.E. model does not account. Its earlier models were actually chastised for hyperbolizing the ever-present threat of drugs and alcohol, counter-intuitively normalizing a behavior that they were trying to stop.

Behaving in accordance with the peer group is not to say that all agency has been stripped from the individual. On the contrary, according to social organization theory, there is an implicit understanding within a group that each individual has a role to play and rules to play by to maintain the order of the social structure (12). As our student example from above is likely the newest member to the social hierarchy, her desire to conform is driven by deeply held socialization that differentiation is the enemy of assimilation. Coupled with her understanding of the rules, as they are manifest by the other, more senior, members of the group, she adheres to the norms established prior to her introduction. If she doesn’t, she runs the risk of being ostracized simply because other members of the group will no longer be able to play by the same set of rules in approaching her as they would if approaching anyone else.

D.A.R.E. scratches the surface of the pressure encountered by young adults on daily basis when confronted with risky decisions. It does not, however, incorporate the pressures of making decisions, as a new actor, within the confines of a group with either limited knowledge or well-earned knowledge. In that scenario, the actor is faced with the seemingly more important decision to either fit in or get out, despite her level self-confidence prior to entering the party.

C.   Critique 3: Self-efficacy will save us all, or at least the children

D.A.R.E. proponents vehemently believe in the Theory of Planned Behavior. The current model is built around the notion that improving a student’s sense of self-efficacy will ultimately empower the student to make the best decision in a high-risk situation, regardless of surroundings. If this is true, then all of the weaknesses noted above are immaterial because the more confident the student is, the less external social and environmental constructs and group behavior will matter. The fatal flaw of this model, however, is the assumption that an agent will always behave rationally.

A hallmark and critical success of the D.A.R.E. model is the focus on the self-esteem of the students. Noted in the same NHTSA guidelines, two additional warning signs for early drug and alcohol abuse are: low self-esteem and shy temperament at a young age (10). This programmatic strength is, unfortunately, only a proximal result of the model: the students reported feeling a bolstered sense of self only immediately after the program’s conclusion (2). If this is a method to counter the impact of the externalities of environment and group behavior, it is ineffective.

This focus appears to be the model’s participation in the transition from the Theory of Reasoned Action (TRA) to the Theory of Planned Behavior (TRB). Past studies have tried to show that the TRB is a somewhat reliable predictor in the underage use of alcohol, as long as the most compelling factors (e.g. attitude toward alcohol, subjective norms, and prerequisite intention to use) align correctly (13). The researchers firmly asserted that as long as a young adult intended to use alcohol, and all of the other social and personal factors were met, he or she would, indeed use alcohol. Perhaps, then, if the students were taught to no longer intend to use alcohol, the risk would be eliminated.

Unfortunately, what the TRB does not take into account are changes to those critical factors that influence intention, while assuming a strictly linear movement from assessment to intent to action (14). Does this theory hold in the context of our party example from earlier? Does the new student have the time and opportunity to weigh her parents’ opinions, her siblings’ opinions, and her friends’ opinions in a moment after she is asked whether or not she would like a drink? Likely not. D.A.R.E.’s vision to empower the participating students to take greater stock in themselves and have faith in their own self-worth is absolutely essential for healthy development. However, as a means of addressing the rather amorphous concept of “self-efficacy” in an effort to impact a nice, but unrealistic, decision-making model, it is idealistic and poses no real lasting beneficial effect for the students.

II.             Proposed Improvement: Every 15 Minutes and Mariah’s Challenge

As vividly as I remember Officer Joe, I remember a day in May when I was in eighth grade. I had just come home from school and I noticed a newspaper article with my older brother’s photo. The headline read, “High School Junior Dies in Tragic Drunk Driving Accident.” The article talked about all of his achievements, how bereaved our family was, and what a shame it was to have lost him that way. I was confused. While I was reading the article, my brother came bounding in to the kitchen and grabbed a snack from the refrigerator. It was safe to say I had no idea what was going on. I came to find out that my brother was part of the Every 15 Minutes program at his high school.

Every 15 Minutes was developed around the statistic that every fifteen minutes, someone was killed in a drunk driving accident. While this statistic is now dated, and drunken driving fatalities have decreased by more than 50%, underage drinking and driving is still a reality. The CDC reported that in 2011, nearly one million high school aged youth drank and decided to drive (15). Clearly there is still a disconnect in the message being communicated by anti-drug programs and the actual behavior of teens and young adults.

The D.A.R.E. program, in an effort to be comprehensive, attempts to educate students on the dangers of multiple drugs and violent acts. Because the program is limited to 16 lessons, the practitioners cannot delve deeply into specifics about a given drug. These recommendations will focus on adolescent drinking and risky behavior associated with the decision to drink. Here we will critically look at two interventions that successfully use social science models to strengthen and brand community of non-alcohol users: Every 15 Minutes and the Mariah Challenge. An effective intervention targeting underage drinking and risky behavior will combine the key elements of both of these programs and will reach more students and resonate more deeply.

A.    Response to Critique 1: Creation of a new community through shared experience

The Every 15 Minutes campaign is a multi-faceted program incorporating various media to bring the reality of drunk driving directly to a student population through simulation. Students from the school will be selected to participate in a mock car collision, where some will play the victims (both injured and dead) and others will play the perpetrators. The simulated accident will take place on the school grounds, and the car (often a car that was actually involved in a drunk driving accident) will remain on the campus for a specified period of time. Those who have “died” will have obituaries written for them, and the school will hold a memorial assembly in those students’ honors. Parents will be notified of the students’ “deaths” and both students and parents will participate in a letter-writing exercise expressing their feelings surrounding the incident. After the “accident” and prior to the memorial assembly, students involved in the “accident” will be taken off campus to participate in a one evening retreat led by local law enforcement officers and counselors, while their classmates are instructed to reflect on the accident witnessed. Individual schools can choose to incorporate or subtract specific elements from the experience, but overall, the program is the same across schools (16).

The brilliance of this intervention lies in its novelty. No matter what the background or former experiences are of the students participating, the entire community together witnesses and works through a tragic accident. This group-level intervention incorporates multiple members of the community, and serves as a unifying event within the school populations’ collective history. If the school chooses to adopt this same intervention annually, the tragedy is not lost on those who have previously experienced it as different students are selected to participate each year. In contrast to the D.A.R.E. one-size-fits-all model, Every 15 Minutes simulates a difficult and tragic event around which an entire community rallies, effectively and lastingly reaching more students than the D.A.R.E. model structurally could.

Emotional and resonant in nature, Every 15 minutes also capitalizes on one recognized strength for addressing underage drinking through school programming: interaction (17). In this intervention, the students are the very center of the appeal and those who are targeted are the students as well. This dramatization exemplifies the central piece of the communications theory, as the victims of this simulation are those with whom fellow students can identify the most. While the simulation initially is not positive in nature, the reintroduction of the students back into the school population brings a sense of relief. After forcing the students to confront the realities of losing a classmate either to arrest, injury, or death by reckless decision making, that relief is much more profound and persistent over time.

B.    Response to Critique 2: Branding a community of non-users

A sense of relief is a feeling that Leo McCarthy has been trying to regain for the last five years. In 2007, his 14-year-old daughter was struck and killed by an underage drunk driver. While giving his daughter’s eulogy, McCarthy made a commitment to provide scholarships to high school students who pledged not to drink until they are 21, not to get into a car with someone who’d been drinking, and to give back to their communities. The pledge can be taken and signed online and as long as a student has not been convicted of any underage possession related offenses, the student is eligible to receive at $1,000 scholarship upon graduation (18).

Mariah’s Challenge is a grass-roots organization that is built on the fifth premise of alternative social science models, and creates a sense of premature ownership in the students who decide to take the pledge. By incentivizing students with the a potential scholarship, McCarthy is forcing the students to commit to a behavior based on an anticipated, but not guaranteed, pay-off without having to buy into the principles or dogmas that would otherwise lead to the desired behavior change. As the students get closer to graduation, the likelihood of winning the $1,000 scholarship is greater and greater and, based on the theories of ownership, the students are more likely to adhere to the pledge regardless of external pressures.

The intriguing facet about this intervention is that it also builds a branded community. In the way that the popular Livestrong campaign has merchandise and identifiable imagery, Mariah’s Challenge has a very recognizable logo and associated pink merchandise that is quickly and easily linked to the cause. In creating this brand, McCarthy has also created a community of inclusion for the students who choose to pledge. Regardless of where those students go, or with whom they interact, they will always be a part of Mariah’s Challenge. With that brand comes the promise of responsibility. Being armed with that is much more potent in the face of making difficult choices than being taught strategies to deal with one-on-one peer pressure, as the D.A.R.E. model would advocate. A member of this Challenge community will always be a member as long as he or she follows through on his or her pledge. Because it is reinforced in a comfortable setting at first, it is something that can transcend the pressure introduced by novel surroundings, new individuals, or a changed culture of acceptance.

C.   Response to Critique 3: Changing social norms

Both the Every 15 Minutes intervention and the Mariah Challenge are working to change the social norms surrounding underage drinking and driving by approaching the community most affected. It was not until recently that the D.A.R.E. program expanded to include high schools. By the time the graduates of the early D.A.R.E. elementary programs reached high school, the value of the program, if any gained at all, diminished. One could thus surmise that any lessons learned were either forgotten or drowned out by other social pressures, personal experiences, or environmental stressors.

By the time early graduates of the D.A.R.E. program reach high school, they are no longer in control of the social norms surrounding drinking culture. They are subject to them. Interventions like Every 15 Minutes and Mariah’s Challenge are forcing high school students to question two assumptions: that it is permissible to drink underage and that driving after drinking is not a serious offense. Every 15 Minutes combines the gruesome reality of drunk driving accidents with the profound emotional impact of losing a loved one to such a horrific incident. It makes tangible the otherwise easily written off threat that drinking and driving poses. Mariah’s Challenge, borne out of such a tragedy, mobilizes a community of committed students to take ownership of their futures. In doing so, they will first change their behaviors, later change their attitudes, and even further down the line, impact others to do the same. These collective changes serve to impact the culture of drinking in the high school environment by changing the subjective norms on the group level.

Changing the subjective norms, particularly those of immediate peers, surrounding the decision or intention to drink while underage would render the Theory of Planned Behavior moot. At the point where norms are changed, the issue of self-efficacy is no longer relevant. Three independent studies evaluating effective strategies for mitigating underage alcohol consumption have all recommended that a concerted effort be placed on changing the societal and community norms surrounding drinking (19)(17)(10). D.A.R.E.’s insistence on the use of individually focused social science models, particularly the TPB, just speaks to its own inability to adapt and evolve in time with the populations they are most trying to impact.

III.           Conclusion

The United States Surgeon General has issued a comprehensive, multi-tiered plan to address the persistent problem of underage drinking (20). She, a newly appointed official, taking such a bold step towards combating this issue is indication enough that current programming has not been working. One of the most ineffective of all of these currently existing is the Drug Abuse Resistance Education program. It is built using individually focused social science theories and fails to take into consideration the pressures of group behaviors and environmental pressures into its model, and the only group suffering are those for whom it was initially intended.

In its wake, other interventions have arisen to address D.A.R.E.’s shortcomings. Programs like Every 15 Minutes and Mariah’s Challenge have built communities around shared experiences and have branded young students as ambassadors of responsibility, imbuing them with a sense of purpose that transcends peer and social pressures. A program with the brand power and sense of ownership of Mariah’s Challenge coupled with the powerful community building effect of Every 15 Minutes could elicit significant change among high school students and young adults. These programs are specialized to target very specific drug related behaviors, compared to D.A.R.E.’s comprehensive, all-encompassing approach, and create a profound and lasting impression on those who participate, adults and students alike.

CNN recently reported on a young woman who lost her father and older brother to a drunk driver in one evening. She has since become an advocate against the behavior and has told her story to multiple audiences. What she’s realized is that her story is much more powerful than any numbers or fact sheets, and she has committed to continue telling her story as long as it proves beneficial to anyone somewhere (21). I don’t remember Officer Joe’s real name, but I do remember my brother’s “obituary” and I won’t forget Mariah’s story

IV.           References

1.             D.A.R.E. [Internet]. The Official D.A.R.E. Web Site: Drug Abuse Resistance Education. Available from: http://www.dare.com/home/default.asp

2.             Ennett, Susan T., Rosenbaum, Dennis P., Flewelling, Robert L., Bieler, Gayle S., Ringwalt, Christopher L., Bailey, Susan L. Long-Term Evaluation of Drug Abuse Resistance Education. Addictive Behaviors. 1994;19(2):113–25.

3.             Objectives for D.A.R.E. School Curriculum [Internet]. 2012. Available from: http://www.dare.org/officers/Curriculum/Storyf98c.asp?N=Curriculum&M=10&S=12

4.             Rosenbaum, Dennis. Program Profile: Drug Abuse Resistance Education (DARE) [Internet]. University of Illinois at Chicago; Available from: http://crimesolutions.gov/ProgramDetails.aspx?ID=99

5.             Drug Abuse Resistance Education: The Effectiveness of DARE [Internet]. Alcohol Abuse Prevention: Some Serious Problems. Available from: http://www.alcoholfacts.org/DARE.html

6.             Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings [Internet]. U.S. Department of Health and Human Services Substance. Available from: http://www.samhsa.gov/data/NSDUH/2k10NSDUH/2k10Results.htm#3.2

7.             Ringwalt, Christopher, Greene, Jody M., Ennett, Susan T., Iachan, Ronaldo, Clayton, Richard R., Leukefeld, Carl G. Past and Future Directions of the D.A.R.E. Program: An Evaluation Review [Internet]. Research Triangle Institute; 1994 Sep. Available from: https://www.ncjrs.gov/txtfiles/darerev.txt

8.             Shephard III, Edward M. The Economic Costs of D.A.R.E. Institute of Industrial Relations; 2001 Nov.

9.             Ethnic Distribution of Pupils by District, Los Angeles County [Internet]. Los Angeles, CA; 1997 2011. Available from: http://www.laalmanac.com/education/ed05_97.htm

10.             Prevention & Education [Internet]. U.S. Department of Transportation; National Highway Traffic Safety Administration; 2001 Mar. Report No.: 4. Available from: http://www.nhtsa.gov/people/injury/alcohol/Community%20Guides%20HTML/Book4_Prevention.html#Current theories

11.             Thaler, Richard H., Sunstein, Cass R. Chapter 3: Following the Herd. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press; 2008. page 53–71.

12.             DeFleur, Melvin L., Ball-Rokeach, Sandra J. Chapter 8: Socialization and Theories of Indirect Influence. Theories of Mass Communication (5th edition). White Plains, NY: Longman, Inc.; 1989. page 202–27.

13.             Marcoux, B.C., Shope, J.T. Application of the Theory of Planned Behavior to adolescent use and misuse of alcohol. Health Education Research: Theory and Practice. 1997;12(3):323–31.

14.             Edberg, Mark. Chapter 4: Individual Health Behavior Theories. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Washington, D.C.: Jones and Bartlett Publishers; 2007. page 191–205.

15.             CDC Vital Signs - Teen Drinking and Driving [Internet]. [cited 2012 Dec 13]. Available from: http://www.cdc.gov/vitalsigns/TeenDrinkingAndDriving/index.html

16.             Every 15 Minutes - Someone dies from an Alcohol Related Collision [Internet]. [cited 2012 Dec 14]. Available from: http://www.every15minutes.com/aboutus/

17.             Komro, Kelli A., Toomey, Traci L. Strategies to Prevent Underage Drinking. NIAAA Spectrum [Internet]. Available from: http://pubs.niaaa.nih.gov/publications/arh26-1/5-14.htm

18.             Grieving father offers teens money not to drink [Internet]. CNN. [cited 2012 Dec 14]. Available from: http://www.cnn.com/2012/06/14/us/cnnheroes-mccarthy-alcohol-challenge/index.html

19.             Holder, Harold D. Community Prevention of Young Adult Drinking and Associated Problems. NIAAA Spectrum.

20.             General S. Surgeon General’s Call to Action to Prevent and Reduce Underage Drinking [Internet]. [cited 2012 Dec 14]. Available from: http://www.surgeongeneral.gov/library/calls/underagedrinking/programs.html

21.             What sways teens not to drink, drive? Stories, not stats [Internet]. CNN. [cited 2012 Dec 13]. Available from: http://www.cnn.com/2012/10/10/us/cnnheroes-underage-drunken-driving/index.html

Thinking Through “Baby Think It Over”: A Proposed Intervention for Teen Pregnancy Prevention--Kate Reed

Introduction

“Baby Think It Over” is a parenthood-simulation program created by Reality Works, Inc. that is used mostly in middle schools as a mechanism to prevent teen pregnancy.  Students are each given an infant simulator named RealCare Baby – a lifelike, life-size baby doll with computerized responses.  According to Reality Works, the doll is set to cry at varying intervals, cueing the students to feed, burp, diaper, or comfort it.  An internal computer monitors how often and how quickly the students respond to the crying, as well as if the doll is shaken, dropped, or otherwise handled roughly.  It even senses if the students do not support the “infant’s” neck.  The teens keep the doll over a weekend in order to experience some of the demands of infant care. 

At its peak, “Baby Think It Over” was used in more than 12,000 school districts and health and service organizations in the US (RealityWorks).  Schools that decide to participate can adjust the program to fit their needs; it is up to the individual school or program to determine which students will participate – girls and/or boys, older or younger. Some schools and programs are unable to use “Baby Think It Over” due to the enormous cost of the program; each infant simulator costs around $700, and schools must also buy baby care supplies and replace infant parts every few years (RealityWorks).  “Baby Think It Over” is unable to provide statistics showing that its doll works – the company wants to collect the data but for now it relies on “strong anecdotal evidence” (Drawbaugh).  In terms of wanted teen pregnancies, the program has been found to have either no effect on the desires of students to be teen parents or to actually increase the number who want to (Kralewski).  Infant simulators are an expensive and complex intervention for teen pregnancy, and their effectiveness is questionable.  One paper states that “simulated experiences can be a powerful strategy for effective learning about complex decisions regarding the risks of sexual activity and the realities of parenting” (Didion), while another paper argues that the “effectiveness of using infant simulators to influence the perceptions of teens about the reality of teen parenting is minimal” (Herrman). 

 “Baby Think It Over” has three fundamental flaws that prevent it from ever being successful.  First, the program has no clear goal and bases its assumptions on the Theory of Reasoned Action.  Second, the program induces psychological reactance in its participants.  Third, the program is ineffectively delivered and gives mixed messages.  The proposed intervention takes a different stance on teen pregnancy prevention, and aims to correct for the three fundamental flaws of the “Baby Think It Over” program previously discussed.

Critique 1

         A major problem of the “Baby Think It Over” program is the lack of a clearly defined goal.  It wants to prevent teen pregnancies, but it does not distinguish between wanted and unwanted teen pregnancies.  It also does not specify whether the solution to teen pregnancy is safe sex or no sex at all.  Ostensibly, the goals of the project are to help students realize the responsibility of having a baby, and presumably that they need to wait before having children.  However, Richard Jurmain, the creator of the program, maintains that the main lessons learned from the program are not about values but "sleeplessness," which as he states, "is a compelling rationale for not getting pregnant” (Cheakalos).

The “Baby Think It Over” program is also based on the Theory of Reasoned Action, and therefore makes incorrect underlying assumptions about why teens get pregnant.  According to the Theory of Reasoned Action, people have rational decision-making processes and skills, and decsions are influenced by two factors: a person’s attitude towards the heavier and their perception of social norms (Edberg).  If the goal of the program is to prevent wanted teen pregnancies, then the underlying assumptions

are that teens actively choose to become pregnant, and that they want to become pregnant because they do not understand how difficult parenting is.  If the goal of the program is to prevent unwanted teen pregnancies, then the underlying assumptions are even more ridiculous: teens choose to have sex, and choose to have unprotected sex, because, again, they do not understand how difficult parenting is.  The problem with this is that human behavior is not always rational, especially when erections are involved (Ariely).  In fact, according to Dan Ariely’s book “Predictably Irrational,” subjects were more than twice as likely to engage in risky sexual behavior and 25 percent less likely to use a condom when asked in a “hot” aroused state than a “cold” non-aroused state.  Also, the majority of teen pregnancies are unplanned, meaning that no rational decision – at least about the difficulty of parenting – was made at all (Finer).

Critique 2

 A second problem with “Baby Think It Over” is the degree to which is induces psychological reactance in its participants.  The program gives students infant simulators to convince them to wait to have children, and therefore in order to be successful the program needs its participants to fail at their parenting tasks.  In reality, some students inevitably end up scoring highly, thereby defeating the whole purpose of “Baby Think It Over” – to prove that parenting is hard.  In fact many students state that they found “Baby Think It Over” to be easier than they expected it to be, and they believe that real infant care will probably be even easier (Kralewski).  More importantly though, according to the theory of psychological reactance, giving teens a message that they “cannot” do something – for example, be a parent – will make them want to do it more.  The theory posits that when people feel that a freedom is threatened, they experience a motivational state aimed at restoring that freedom (Silvia).  “Baby Think It Over” induces psychological reactance because it is attempting to take away teens’ freedom to have sex, something which nearly-mature bodies and still-maturing minds are intensely concerned with. 

Critique 3

         A final critique of the “Baby Think It Over” program is the way it is delivered – the instructor is not effective and the program has implicit mixed messages.  Because teens as young as thirteen take part in this program as a school project, it is important for the instructor to be relatable and respectable.  The instructor is often not relatable to the students due to age and race differences.  The program is also delivered with mixed messages: the students are told to take the project seriously and reflect upon the hardships of being a teen parent, but at the same time they are given bonus points if they take lots of pictures with their “baby” and create “family” photo albums (Borr).  As previously stated, although the program is based on a premise that students will fail, this is not always the case.  Not only do students often find the project to be easy, they also find it to be fun – some students throw baby showers and birthday parties for each other and their “babies” (Borr).  The mixed messages, combined with the fact that they are coming from a non-similar, not necessarily respected adult, do not create a strong lasting impression.

Proposed Intervention

         The proposed intervention aims to correct the fundamental flaws present in “Baby Think It Over” with a new intervention focused on empowerment and control.  The data is unclear on whether or not infant simulators have the potential to be effective in preventing teen pregnancy, even if the program surround the simulators is changed.  Therefore, the proposed intervention will abandon the use of infant simulators.  Also, because the proposed intervention is not assuming that teens get pregnant for lack of parenthood knowledge, an infant simulator is unnecessary anyways.

         In reality, teens get pregnant due to an interacting web of factors, but one of the most significant underlying factors is a feeling that they are not in control of their own lives.  The teenage brain is not fully developed, and teens are more likely to engage in risky behavior, think less about consequences, and focus on only immediate effects and consequences than a fully developed adult brain (Hedaya).  When teens feel that their futures are not under their own control, their inherent inability to think rationally is compounded.  In terms of sexual behavior, they are more likely to engage in unprotected sex, have multiple partners, and generally increase their risk for pregnancy (National Campaign).  The feeling of a lack of control arises from a number of factors such as low socioeconomic status, life stressors, living in an impoverished area, and community or cultural norms.  If teens live in an area where no one reaches their goals then the teens will not expect to reach their own goals either.  Likewise, if teens see their peers having children young then they will begin to think it is the norm.

         What the proposed intervention aims to do is break this cycle of learned helplessness by empowering teens.  The core value of the program is “control.”  Teens in high risk areas will be part of small focus groups, available at school or through community centers, where they will have discussions and do exercises that focus on empowerment and controlling their own lives. 

Defense 1

         The proposed intervention has a clearly defined goal: to make safe sex the natural choice in order to prevent unwanted teen pregnancies.  The intervention acknowledges that many teens will chose to participate in sexual activity, and rather than explicitly attempting to prevent that activity it will instead attempt to make it safe.  The intervention aims to prevent unwanted teen pregnancies because the majority of teen pregnancies are unwanted, and because the underlying factors in wanted teen pregnancies are far more complex and beyond the scope of the intervention.

         In order to make safe sex the natural choice, the intervention will focus on empowering teens to realize why safe sex is the best option for them.  The underlying assumption of the intervention is that unwanted teen pregnancies happen because of a lack of control.  According to Kathryn Edin’s book “Promises I Can Keep,” women who have no access to opportunities use children as validation; the unconditional love of a child and the attention they bring is a replacement for academic or professional success, intimacy, etc.  In a way “Baby Think It Over” reinforces this because other people often give participants excessive attention while they are caring for their “baby” (Borr).  To address this, the proposed intervention will empower teenagers to realize their opportunities, dreams, and desires, and that getting pregnant will reduce the control they have over their own futures.  This will be a lot more effective than patronizingly assuming that teens get pregnant because they are ignorant to the trials of parenthood. 

Defense 2

         Where “Baby Think It Over” induces psychological reactance by impeding on personal freedom, the proposed intervention will instead make teens induce psychological reactance on themselves by getting them to visualize themselves fulfilling their dreams, so if they do something that prevents those dreams, such as getting pregnant, then they are taking away their own freedom.  The intervention also aims to increase the number and kind of positive freedoms teens feel they have.  Many teens have an optimistic bias about teen pregnancy, thinking, “It won’t happen to me.”  Optimistic bias is the tendency of people to be unrealistically optimistic about their own future life events and the expectation of others to be victims of misfortune rather than themselves (Weinstein).  Even if teens do realize their susceptibility to the threat of teen pregnancy, they often have an inverse illusion of control and feel like whether or not they get pregnant is not under their control.  The illusion of control is an expectancy of personal success greater than is appropriately warranted due to an incorrect assumption of control over chance situations (Langer).  Therefore, an inverse illusion of control could be thought of as an incorrect assumption of chance in situations which one does have control over; learned helplessness in a sense (Langer).  The program will address these things by talking about different contraception choices as well as healthy relationship practices, showing teens that pregnancy is within their control and it is their freedom to exercise that control.

         It is also important that the program not increase the stigma of being a teen parent further.  Many teenagers in high risk areas have exposure to teen parents – they know teen parents, they were the child of a teen parent, etc.  Therefore, a program that is insensitive and not careful in its language and underlying messages will increase psychological reactance by angering and alienating the participants.  Furthermore, it is important for teens who are already parents to know that it is still possible, on some level, to achieve their dreams and desires.  The program does not aim to say “you cannot achieve your dreams with a baby;” it simply aims to say “reaching your goals is easier without a baby.”

Defense 3

“Baby Think It Over” struggles to leave a lasting impression on its participants due to its mixed messages and non-similar instructors.  Communications theory and the theory of psychological reactance both show that a message is more effective and persuasive if the person delivering it likeable, familiar, and similar to the target population.  Furthermore, the message itself should be clear and concise, have justification, and have positive associations.  For this reason, the program will be delivered by role-models who are similar in race and age to the target population, and likeable.  The program will also engage familiar community leaders to back the message, further increasing its effectiveness.  For example, if the program is being implemented in a school then a well-liked student body president will be involved in delivering the program.

This piece of the program is particularly necessary for encouraging condom usage.  Social expectation theory shows that individuals take behavioral cues from groups by observing the social norm (DeFleur).  Therefore, if the program makes condoms appear to be the social norm, they will in fact become the norm.  There are several ways in which the program will attempt to make condoms the social norm.  First, the familiar community leaders will endorse them.  Second, condoms will be readily available and free in schools, community centers, apartment complexes, and anywhere else the program is implemented.  Third, advertising for condoms that is created by the program will bear a promise of control over one’s own life and will contain popular music and images.  In this way, the program can attempt to alter social norms and make condom usage the natural choice.

Conclusion

         “Baby Think It Over” is a fundamentally flawed program for three reasons: it has unclear goals and incorrect assumptions based on rational behavior patterns, it induces psychological reactance in its participants, and it is delivered ineffectively and with mixed messages.  The proposed intervention to prevent unplanned teen pregnancy corrects for those fundamental flaws by setting clear goals based on accurate assumptions about teen sexual behavior, it is formatted to minimize psychological reactance, and it is delivered in an effective way following theories of communication and social norms.  Ultimately, the proposed intervention would enhance teens’ feelings of control over their own lives and help them to realize their life potential.  Combined with effective advertising and adjustment of social norms in the community, this would make safe sex the natural choice.

Works Cited

§  Ariely, Dan. Predictably Irational: The Hidden Forces That Shape Our Decisions. New York: Harper Perennial, 2009.

§  Borr, Mari L. “Baby Think It Over: A Weekend with an Infant Simulator.” Journal of Family & Consumer Sciences Education (2009). NATEfacts.

§  Cheakalos, Christina. “Shrieking Baby Doll Gives Jolt of Parenthood for Teenagers.” Editorial. Herald-Journal [Atlanta] (1994). Google News.

§  DeFleur, M. Theories of Mass Communication. White Plains, NY: Longman Inc., 1989.

§  Didion, J., and H. Gatzke. “The Baby Think It Over Experience to Prevent Teen Pregnancy: A Postintervention Evaluation.” Public Health Nursing (2004). PubMed.

§  Drawbaugh, Kevin. “Baby Doll Teaches US Teens about Parenthood.” Editorial. The Nation [Chicago] (1997). Google News.

§  Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publisher, 2007. Course Reader.

§  Edin, Kathryn, and Maria Kefalas. Promises I Can Keep: Why Poor Women Put Motherhood before Marriage. Berkeley: University of California, 2005.

§  Finer, L.B., and Kost, K. “Unintended Pregnancy Rates at the State Level.” Perspectives on Sexual and Reproductive Health (2011).

§  Hedaya, Robert. “The Teenager’s Brain.” Psychology Today (2010).

§  Herrman, J.W., J.K. Waterhouse, and J. Chiquoine. “Evaluation of an Infant Simulator Intervention for Teen Pregnancy Prevention.” Journal of Obstetric, Gynecologic, and Neonatal Nursing (2011). PubMed.

§  Kralewski, J., and C. Stevens-Simon. “Does Mothering a Doll Change Teens' Thoughts about Pregnancy?” Pediatrics (2000). PubMed.

§  Langer, E. “The illusion of control.” Journal of Personality and Social Psychology (1975). Course Reader

§  National Campaign, The. The National Campaign to Prevent Teen and Unwanted Pregnancy. Web. [http://www.thenationalcampaign.org/]

§  Reality Works, Inc. Realityworks - Experiential Learning Technology. Web. [http://www.realityworks.com/]

§  Silvia, Paul. “Deflecting reactance: The role of similarity in increasing compliance and reducing resistance.” Basic and Applied Social Psychology (2005). Course Reader.

§  Weinstein, N. “Unrealistic optimism about future life events.” Journal of Personality and Social Psychology (1980).  Course Reader

When Less is More: A Critique of Cigarette Health Warning Labels – Vania Lin

Background Information

            The U.S. Food and Drug Administration (FDA) sought to replace in September 2012 the current text-only health warning labels on cigarette packaging with larger warnings and graphic images.  The new labels consisted of messages such as “WARNING: Cigarettes cause fatal lung disease.” and “WARNING: Smoking can kill you.” that are accompanied by images including diseased lungs and corpses.  One of the stated goals of this change was to “empower youth to say no to tobacco” (1).  Court proceedings in the case of R.J. Reynolds Tobacco Co. v. U.S. Food and Drug Administration, the lawsuit tobacco companies brought forth against the FDA, have delayed the implementation of the new warnings (1).  With the U.S. Court of Appeals in Washington, D.C., denying to rehear the case as of December 5, 2012, the final say on implementation may be left up to the U.S. Supreme Court should the government decide to appeal (2).

Overview of the Critique

            The effectiveness of the new graphic labels in preventing smoking initiation in adolescents is questionable.  In particular, the warnings neglect to address the effects of branding on adolescent smoking and the formation of social identity.  The labels also overvalue the importance of health to adolescents.  In their failure to take into account the values that adolescents hold in high regard, such as independence and reputation, the warnings have weak impact on adolescent smoking prevention and may even encourage adolescents to start smoking.  Lastly, the labels will likely trigger psychological reactance, which would incite rebellion against the warnings and may even provoke smoking initiation.

The Implications of Branding

            The graphic warning labels fail to address the importance of branding in adolescent smoking and social identity.  The new labels may be more prominent, but they do nothing to eradicate the associations that tobacco companies have designed cigarette packaging to convey.  Adolescence is characterized by experimentation and the formation of identity; it is the time in life when people are most likely to start smoking.  Escobedo, Anda, Smith, Remington, and Mast (1990) found that smoking initiation sharply increases after eleven years of age and reaches its peak between seventeen to nineteen years of age before rapidly declining through 25 years of age and gradually declining in older age groups (3).  Tobacco companies, armed with this knowledge, aim to attract people to smoking at a young age.  In a revealing study conducted in Tracy, California, Henriksen, Feighery, Schleicher, Haladjian, and Fortmann (2004) found that stores where youths shopped at more frequently had almost three times the amount of tobacco marketing materials and considerably more shelf space for the major cigarette brands Marlboro, Camel, and Newport than other stores (4).  This finding highlights the connection between marketing of cigarettes by tobacco companies and adolescent smoking.

Branding plays a large role in the marketing scheme: the cigarette brand name, the visual logo, the pack design, and the color scheme all come together to create branding signals that represent the brand’s core values (5).  Scheffels (2008), in a series of interviews conducted with young smokers in Norway, found that young smokers formed social identities and established social status based on their choice of cigarette brand.  For example, the Scandinavian brand Prince, which contained a picture of a cigarette on its red packaging, was seen as strong, harsh, and of low social status, while Marlboro Light, with its gold-lettered white packaging and foreign origin, was associated with femininity and higher social class status.  What is striking is that Norway has banned advertising for tobacco since 1975; despite the ban on advertising, tobacco companies have and continue to succeed in branding their cigarette products to attract different populations of young people.  The actions of the Scandinavian Tobacco Company, which manufactures Prince cigarettes, support the assumption that tobacco companies extensively research the effects of branding themselves—soon after Scheffels conducted the interviews, the company replaced the blunt image of the cigarette with that of subtle floating smoke on Prince packs (6).  Without curbing the advertising effect of the cigarette packing itself and severing the link between smoking and social identity, the new warning labels are unlikely to have a large effect on the prevention of adolescent smoking.

Overvaluation of the Importance of Health

            The graphic warning labels centered on the harmful health effects of smoking overestimate the importance of health to youths.  The effectiveness of the warnings is based on the assumptions that adolescent smokers value health highly and that knowledge of the health risks of smoking will deter youths from smoking.  In contrast to these assumptions, Virgili, Owen, and Severson (1991) found that adolescent smokers, compared to ex-smokers and nonsmokers, had a harder time imagining the harmful health effects of smoking in themselves and tended to downplay the severity of the health risks.  Smokers also perceived greater benefits of smoking relative to the risks of smoking (7).

Lee, Buchanan-Oliver, and Johnstone (2003) further explored the relationships between adolescent characteristics and values and smoking.  They found that the sense of being invulnerable persisted in adolescents despite their knowledge of the health effects of smoking.  The authors characterized this aspect of adolescence as the “personal fable”: adolescents have a hard time separating personal beliefs from universal principles.  In the case of smoking, adolescents may rationalize that, although smoking does cause harmful health effects, these conditions would occur in other people but not in themselves because of their inherent uniqueness and difference from others.  This denial mechanism contributed to the study participants’ heavy focus on the benefits of smoking, such as being perceived as cool or sophisticated, and their relatively light focus on the negative aspects of smoking.  The authors also found that adolescents were motivated to smoke by the belief that smoking was an act of rebellion; risk-taking was a declaration of independence and a way to build reputation and establish social identity.  As one participant succinctly put it, “You do things because they are bad for you.  ‘Cause you do things to take a risk” (8).  In overvaluing the importance of health and failing to take into account qualities that adolescents value highly, cigarette labels emphasizing health risks are unlikely to be effective in preventing adolescent smoking and may even have the opposite undesirable effect of encouraging smoking among adolescents.

The Effects of Psychological Reactance

            The graphic labels will likely trigger psychological reactance in adolescents and exacerbate the problem of adolescent smoking.  The theory of psychological reactance asserts that people believe that they are free to make their own choices and shape their own behavior.  When they are faced with a force, such as a persuasive message, that is seemingly trying to dictate their choice or behavior, they will act to restore their freedom.  One way to do so is to rebel against the force (9).

Dillard and Shen (2005) described the three aspects of a message that contribute to psychological reactance: dominance, explicitness, and reason.  Dominance is the degree to which the message imparts the belief that the source can control its audience.  Explicitness is the extent to which the message conveys the source’s purpose.  Reason is the justification the message provides to convince the audience to adopt the source’s view.  In general, dominance in a message incites anger and psychological reactance, while reason decreases psychological reactance.  The effect of explicitness varies and depends on context, but usually works in favor of persuasion and generates positive emotions (10).

            The elements of the new graphic warnings will likely incite psychological reactance in adolescents.  The messages are highly dominant: the capital letters of “WARNING,” along with the severe messages and extreme images, combine to make the labels take on an authoritative and almost condemning tone.  The labels are explicit in delivering their message, which is likely not a positive factor here in convincing adolescents not to smoke but rather an instigator of anger and psychological reactance.  Their explicitness makes clear that the government is trying to influence the adolescents’ behavior through the warnings.  The reason provided in the messages is tenuous: smoking certainly causes the conditions described by the messages and depicted by the images in some people, but their extreme nature may cause youths to dismiss these warnings as scare tactics.

Erceg-Hurn and Steed (2011) showed that graphic labels triggered heightened psychological reactance.  They measured the level of psychological reactance in smokers after the smokers were exposed to text-only or graphic labels, both of which were in use in Australia at the time of the study.  The tested labels contained messages such as “Smoking Kills.” and “Smoking Causes Mouth and Throat Cancer”; photographs accompanied the graphic labels.  Erceg-Hurn and Steed found that 51.2% of smokers experienced no psychological reactance after viewing text-only labels; only 8% of the smokers who did experience reactance experienced it at a moderate to high degree.  In contrast, over 80% of smokers experienced psychological reactance after viewing graphic labels, and 30.4% of these smokers experienced a moderate to high level of reactance (9).  These results can reasonably be generalized to adolescents—adolescents, with their tendency to rebel, may experience even greater levels of psychological reactance than adults.

Furthermore, Miller, Burgoon, Grandpre, and Alvaro (2006) determined that psychological reactance was a major risk factor for smoking behavior.  They surveyed students in grades six through twelve (ten to twenty years of age) to examine the significance of variables that may contribute to smoking behavior.  They found that increased psychological reactance, decreased age, poor school performance, previous experimentation with smoking, and having friends who smoke were the major predictors of smoking behavior.  Poor communication with parents was also a predictor of smoking behavior, though to a lesser extent.  In addition, psychological reactance was a significant risk factor even among adolescents who did not smoke and had not previously experimented with smoking (11).  The findings of these studies demonstrate that the new graphic labels have a high likelihood of triggering psychological reactance in adolescents and, contrary to their goal, may prompt some adolescents to begin smoking.

Proposed Alternative Intervention

            An effective alternative approach may be to utilize plain packaging and warning messages focused on independence and self-affirmation rather than on health.  In plain packaging, the color, size, material, and the opening method of cigarette packs are standardized.  Packs are distinguished by their brand names only, which appear in the same color, size, and font and at the same location on all packs.  No other writing, excluding health warnings, or visual images are allowed (12).  Plain packaging would thus effectively eliminate the associations created through branding.

The warnings would focus on the aspects of independence and control rather than on health and would draw upon the theory of self-affirmation.  The messages would be phrased in the form of questions.  The goal is to prompt adolescents to question the effect that smoking has on their freedom and control without triggering psychological reactance.

The Power of Plain Packaging

            Replacing the current multitude of cigarette packaging designs with a single, standardized plain design eliminates the venue for branding.  Branding relies on the coordination of elements including the brand name, the color scheme, and visual logos to create distinct characteristics for each cigarette brand; branding can only be accomplished if tobacco companies are able to differentiate the cigarette brands with unique traits.  Plain packaging blocks this route by standardizing all pack designs.  The only aspect that would be different between each brand would be the brand name—and even that would appear in standardized font and at the same location on each pack.  Wakefield, Germain, and Durkin (2008) demonstrated that plain packaging successfully removed brand associations.  In the study, smokers rated the attractiveness of cigarette packs that are shown both in their original packaging and in progressively plainer packaging.  Participants also rated the smokers of these cigarettes on various qualities, including stylishness, class, and confidence.  Lastly, participants rated how satisfying smoking the cigarettes from each pack would be.  Wakefield et al. found that smokers rated original packaging as most attractive, with the ratings dropping as the packaging became progressively plainer.  Participants gave smokers of plain packs lower ratings on positive qualities (e.g., less stylish, less sociable, less mature) than smokers of original packs.  They also responded that smoking cigarettes from plain packs would be less satisfying and that the tobacco would be of poorer quality (13).  These findings show that plain packaging reduces the attractiveness of cigarette packs and removes much of the positive associations (e.g., trendiness, youth, class) that tobacco companies seek to brand their products with.

A Shift in the Focus of Warnings

            Warnings on the cigarette packs focusing on independence and control would likely have a greater impact on youths than those focusing on health.  Adolescents value independence and autonomy highly, while health is not as valued in part because of the sense of infallibility.  Messages that focus on health would likely trigger the adolescents’ cognitive “personal fable” defense.  For example, when asked about cigarette health warnings, one adolescent responded, “No, I don’t think that I am going to die younger, I don’t believe that” (8).  In contrast, messages that frame smoking as threats to their independence and control bring the warnings much closer to the adolescents’ lives.  Take for example the following message: “You are independent and in control: why let nicotine addiction change this?”  The message centers the issue on independence and control, importance aspects of adolescence; this increases the likelihood that adolescents would pay attention to the message.  The message also alerts them to the fact that they are no longer infallible—the very act of smoking, what they thought was a way to rebel against authorities, may now take away their freedom.  As such, warnings on cigarette packs that focus on the effects that smoking has on freedom and control would be more effective in gaining the attention of adolescents than those that focus on health.

The Usage of Self-Affirmation and Questions

            Incorporating self-affirmation into the warnings on the cigarette packs and phrasing the warnings in the form of questions would help reduce psychological reactance in adolescents.  The theory of self-affirmation posits that people are motivated to protect their self-integrity and self-worth and that threats to these aspects of their identity drive people to react defensively.  However, when another aspect of their identity is affirmed in some way in the presence of a threat, the need for defensiveness is lowered (14).  Hogan and Speakman (2006) utilized this concept in developing a “covert persuasion trick”: “Resistance is diminished when people agree with the presented point of view.  Affirm the individual’s point of view” (15).  Harris and Napper (2005) examined the responses of young women to messages describing the link between alcohol and breast cancer.  Participants in the self-affirmation condition were asked to  write about the most important value in their life, the reason for its importance, and how they incorporated the value in their daily lives.  Participants in the control group were asked to write about why the least important value in their lives might be important to others.  All the participants were exposed to information regarding alcohol and breast cancer afterwards.  Harris and Napper found that the participants in the self-affirmation group, some of whom drank a significant amount, were more receptive to and more willing to consider the personal relevance of health messages regarding the connection between alcohol and breast cancer than those in the control group (14).

In a similar vein of investigation, Armitage, Harris, Hepton, and Napper (2008) demonstrated the use of self-affirmation in a study involving adult smokers.  Participants in the self-affirmation group were asked about past acts of kindness, whereas participants in the control group were asked about unrelated issues (e.g., asked for their opinion on whether chocolate was the best ice cream flavor).  All participants were then presented with antismoking information that described the harmful health effects of smoking and were asked a series of questions regarding their smoking behavior (a measure of risk), their view of the importance of smoking cessation (a measure of acceptance), and their intention to quit (a measure of intention).  The participants were offered leaflets containing information on how to quit smoking, and the experimenter covertly recorded this as a measure of effect on behavior.  The authors found that participants in the self-affirmation group showed significantly greater acceptance of the message and greater influence by the message in intention and behavior (16).

These findings demonstrate the effectiveness of self-affirmation in decreasing defensiveness and promoting changes in health-related behavior.  The study conducted by Armitage et al. is particularly relevant, as it addresses the issue of smoking cessation.  In preventing smoking initiation in adolescents, self-affirmation can similarly be used to decrease defensiveness, specifically psychological reactance, when delivering warnings on cigarette packs.  The previously used example message “You are independent and in control: why let nicotine addiction change this?” embodies this principle.  The first part of the message “You are independent and in control” is a self-affirmation mechanism: adolescents would self-affirm that they are independent and in control of their lives.  This reduces the defensiveness that is elicited by the second part of the message “why let nicotine addiction change this?”  Presented by itself, this part of the message would appear to be a direct attack on adolescents’ behavior and would provoke strong defensiveness and psychological reactance.  However, with the mitigating effect of the self-affirming part of the message, adolescents are more likely to experience less defensiveness and psychological reactance and to consider the personal relevance of the message.

Phrasing the warnings on the cigarette packs as questions would reduce psychological reactance as well.  Glock, Müller, and Ritter (2012) showed smokers cigarette packs that had text-only health warning labels, graphic health warning labels, health warnings phrased as questions, or no health warning labels printed on them.  They found that participants perceived higher risks for smoking-related diseases after viewing cigarettes packs that contained warnings phrased as questions or no warning labels.  The authors hypothesized that this may be due to lower levels of defensiveness that would otherwise have interfered with risk perception, an indirect measure of psychological reactance.  Here, lower perceived risk would indicate a higher level of defensiveness.  Furthermore, past research literature has shown that self-generated arguments are more persuasive than those originating externally; this may be why the warnings phrased as questions were more effective in the study.  Although the absence of warning labels appeared to be effective as well, the total lack of information on the harmful effects of smoking is undesirable.  As such, warnings phrased as questions may be the best method of delivering antismoking messages (17).

The message “You are independent and in control: why let nicotine addiction change this?” draws upon these findings by phrasing the warning as a question.  The question format avoids a tone of dominance.  Instead of delivering an authoritative statement, the message poses a question to adolescents and invites them to consider the issue.  The message is explicit in its meaning, but is not condemning; the clarity of the message serves to enhance the self-affirming aspects of the message.  The message contains a reason that adolescents can identify with: the message acknowledges the importance of independence and control to adolescents and asks them to weigh these values against smoking and addiction.  The combined effects of lowered dominance, heightened explicitness, and heightened reason in the message reduce the level of psychological reactance and increase the likelihood that adolescents will be receptive to and consider the meaning of the warning.

Conclusion

            Rather than implementing graphic cigarette health warning labels, instituting plain packaging of cigarettes and using warning messages that focus on independence and control may be more effective in preventing smoking initiation among adolescents.  Messages should furthermore embody self-affirming qualities and be presented in the format of questions.  The combination of plain packaging and self-affirming, questioning cigarette warnings eliminates the effects of branding, draws attention to the warnings through the focus on independence and control, and reduces psychological reactance.  Together, these measures maximize the effectiveness of cigarette warnings and their impact on adolescents.

REFERENCES

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