Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

“Just Say No”: Why One of the Largest Prevention Campaigns was Destined to Fail- John H. Murphy

Anti-drug campaigns have been a prominent part of American culture since the early 1980’s and the introduction of the “War on Drugs”. Most of these initiatives have not done well in regards to curbing adolescent drug use. One of the worst campaigns was the Reagan initiated “Just Say No” initiative. Created in the 1992, the campaign sought to abolish drug use through concept of empowering young people by making them realize they had the power to not do drugs, improve their self-esteem, and thus their lives. Unfortunately, this proved to be quite untrue. This particular initiative failed for a multitude of reasons, with some of the most prominent being that it was based on a flawed model of behavior, actually increased drug use by making it appear prevalent, and because of the fact that drug use and culture are embedded in corporate America.

The “Just Say No” campaign’s failure was, in large part, due to the fact that it was created using an outdated and flawed model for behavior: The Health Belief Model. One of the most important issues with the HBM is the fact that it is based on individual level, rational decision making (1). The very name of the campaign implies that the person confronted with the decision as to whether or not to use drugs, has the ability to make the rational decision to not do so. Obviously, this is untrue, as so many young people engage in drug use. If the healthy, logical decision to not do drugs was so simple, this would not be the case. This issue is also important in regards to the concept of intention leading directly to behavior, which is something else that the HBM assumes. By making this assumption, HBM ignores the fact that many other factors (environmental, social, etc.) can influence the outcome of the intention to do something (1).

The second issue with the HBM is that it fails to acknowledge the role that social factors play in health behavior and decision making (2). These factors, along with environmental, SES, etc cannot be ignored because, for many young people, the desire to not do drugs may pale in comparison to the desire to fit in with their peers, be accepted by larger social groups, or feel supported. Simply, it is often much too intimidating to “just say no.”

The HBM is also flawed in its definition of choice and how people weigh the options. In the HBM, it is assumed that people weigh the pros and cons of a behavior as strictly black and white. That is to say that a behavior that is negative, will be negative for everyone, as was noted in recent litigation against Big Tobacco:

To me it’s like any other form of pleasure, whether it’s jogging, drinking beer or smoking cigarettes. If it provides a benefit to the the eyes of the beholder, if it makes that person feel better about himself or herself,... There is a benefit, otherwise you would not sell the number of cigarettes that we sell every year...” (3).

Clearly, the benefit of a particular behavior is something that is unique to the individual and assuming that behavior is all or nothing fails to acknowledge this very important aspect of human psychology.

The final problem with the HBM is that it assumes that all human behaviors are in concert. That is to say that the intention to not do drugs will fall in line with all other intentions, such as the desire to do well in school. This was a major issue in the “Just Say No” campaign and many others after it. In multiple advertisements, young people who did not say no were depicted as being losers with no desire to, often, do well in school. This demonstrated the immediate and assumed link between the two. For example, while most people don’t want to be overweight, it does not mean that they don’t want to eat cheeseburgers, as noted in, “health beliefs compete with an individual's other beliefs and attitudes” (4).

The “Just Say No” campaign actually made more kids do drugs. By disseminating advertisements and interventions that showed drug use as prevalent, the campaign was showing teens that drug use was a common behavior, engaged in by many. This, when linked with the desire to be part of a group, which is incredibly strong because it feeds natural instincts: comfort, support, protection, love, etc., may have increased drug use. This was demonstrated in a study published in the Journal of Consulting and Clinical Psychology in 1999. The researchers found that the “Just Say No” and DARE campaigns not only did not decrease teen drug use, but that they actually led to an increase. They concluded that this was to the fact that the campaigns made drugs seem very prevalent and they also showed young people engaging in the illicit behavior. In turn, teens may have seen people their age engaging in an activity shown to be prevalent. Because of the desire to fit in, this combination could have led to increased usage rates (5). Recently, another study, to be published next month in the American Journal of Public Health, came to the same conclusion:

“Our basic hypothesis is that the more kids saw these ads, the more they came to believe that lots of other kids were using marijuana,” Hornik said. “And the more they came to believe that other kids were using marijuana, the more they became more interested in using it themselves” (6).

In the same study, researchers showed that as the number of ads seen per month increased, so did marijuana use. For teens that saw 12 or less ads per month, 82% reported no drug use. This number dropped by 6% with teens who saw over 12 and continued along this path as the number increased (6).

All of this is not to say that saturating the market with the messages that are trying to be conveyed is ill-advised. On the contrary, models, such as the diffusion of innovations theory, demonstrate the importance of doing just that. Otherwise, how else can one hope to reach the target audience with any effectiveness? However, the message that is being conveyed must be relevant to that audience. If it is not, it may have the opposite effect and actually reinforce the negative behavior. The “Just Say No” campaign is not alone in having a so called “boomerang” effect (6). The safe sex initiative of the mid 1980’s and 1990’s that was intended to improve safe sex behavior in MSM had just the same effect. The initiative sought to educate men about the dangers of unprotected sex by reinforcing the highly negative consequences of contracting HIV. This initially worked well because of the high levels of fear regarding the disease in the population. However, as treatment and subsequently life span for those with HIV improved, the effectiveness of the campaign began to crumble. In fact, by the mid 1990’s, increased rates of unsafe sex were being reported in MSM. Researchers believe that this was due to the fact that the fear based tactics of the message was no longer relevant to the intended audience. These men no longer viewed HIV as a death sentence and actually reported having “treatment optimism”. Also, because these men were repeatedly being told “you MUST always have safe sex”, many of them viewed not doing so as an act of rebellion (7). This is very similar to the effect of the “Just Say No” campaign. The message was not relevant, even laughable to many teens, and for some, the act of doing drugs was an act of anti-conformity and rebellion.

Because of these findings, it seems appropriate that in order to combat teen drug use, campaigns should focus on young people who aren’t doing drugs. The “truth” campaign is an example of an initiative that sought to target its intended audience in just this way. The researchers for the “truth” campaign discovered that “youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making.” After discovering this and marketing the “truth” campaign as a brand of rebellion in Florida, tobacco use by teens in the state dropped 7.4% in the first 30 days (8).

The third and some could argue most difficult issue to resolve, reason for the failure of the “Just Say No” campaign is the fact that drug use, especially marijuana, is embedded in corporate America. Corporations make “decisions about the production, pricing, distribution, and promotion of their products and political efforts to create an environment favorable for their business” (9). At its most basic level, it is a “how can we make the most money possible, regardless of the means” mentality. Because of this, young people are perpetually provided positive reinforcement for the use of illegal drugs by corporations and people that they view to be cool or even role models. Hollywood is the perfect example. Shows such as Entourage display people smoking Marijuana on a daily basis and being no worse for the wear. The show also happens to be predominantly viewed by 18-30 year old men, who are also the heaviest users of pot. It is not hard to decide which one, Entourage or a “Just Say No” ad, a young man would rather watch and what their association, negative or positive, would be with marijuana. Clothing is another example. Walk into any Pacific Sunwear and it won’t be hard to find hoodies, hats, and belts emblazoned with pot leaves. These shows and articles of clothing are viewed as much cooler than anti-drug ads, and are also used as a form of rebellion by, again, demonstrating anti-conformity.

The demographic that corporations target is also of importance. Multiple studies have shown that people who have low SES have greater risk for negative health behaviors such as, smoking cigarettes, alcoholism, drug use, and unsafe sex (10,11). These facts are no secret to corporations. For many businesses, these population groups are a prime target for their products. For example, the media outlet BET and clothing store Urban Behavior’s target demographic are African-American men between 18-30 years old. It is not unusual to see many of their products (music videos, shows, hats, shirts) displaying many references to the positive aspects of drug use: you will get women, wealth, friends, etc. Tobacco marketing is a prime example of corporations doing just the same thing. Studies have shown that neighborhoods with low SES have higher tobacco marketing saturation rates because there will be a larger proportion of smokers and possible smokers in those neighborhoods (12).

Recently, large corporations (Merck, Firestone) have been found to have been aware the negative health effects of their products, but continued distribution because of the high profit margins, and even “conducted extensive public relations and lobbying campaigns to try to maximize financial returns” (9). While these specific instances are extreme, they are not unlike the Hollywood executive producing a show glorifying drug use. They know exactly what effect it will have on the viewer, because they have put the time and money into the research. In contrast, the “Just Say No” campaign was based around a single, cheesy catchphrase: just don’t do it. This is no match for the huge influence corporate America has on behavior. Businesses employ hundreds of marketers, advertisers, and psychologists to determine what factors influence the choices of consumers. Corporations then take the wealth of information learned through their research and are able to create products and then market, distribute, and price them in a manner that elicits a strong, positive, and often subconscious reaction from the targeted group (13).

To alleviate the negative impact of corporate practices the glorify drug use, it will be necessary, not to create new, stronger anti-drug campaigns, but rather, provide consumers with adequate knowledge about the negative health impacts of drug use while protecting the young and especially vulnerable groups, increase penalties for disseminating pro-drug products, and increase health and policy spending to level the playing field (9). Otherwise, huge corporations, such as film and TV studios and clothing manufactures will always be able to out spend health campaigns while marketing their product in a manner that creates the perception of coolness by the consumer.

In hindsight, it is not surprising that the “Just Say No” campaign was unable to deter adolescent drug use. The entire campaign was based on a model of behavior that reduces decision making and behavior to an individual cost v. benefit analysis. It also saturated media outlets, schools, etc with a message that showed drug use as something prevalent in young people, which may have actually increased usage rates. The fact that drug culture is something that is so highly embedded in American culture and business also played a significant role in undermining this and many other campaigns. In order to reduce teen drug use, it will be important for initiatives to use the message as a brand that assumes no rational thinking and takes into account the many pressures young people face.

The “Just Say No” campaign was inherently flawed and destined to fail because of its creators unwillingness to accept or unawareness of the fact that adolescent drug use is more than a simple yes or no decision, should be displayed as an act of the minority rather than the majority, and that drug culture is highly rooted in the practices and products of corporate America. In order to reduce teen drug use, it is imperative that each of these issues be incorporated into future campaigns. If the multi-factor causes of drug use are not acknowledged, anti-drug campaigns will continue to have little effect.

One of the greatest flaws of the “Just Say No” campaign was its utilization of an already outdated model of behavior, the Health Belief Model. In order to construct an intervention that would not be inherently flawed, the core issues of the HBM must be addressed. For instance, the HBM assumes health behavior is based on rational, logical decision behavior (1,2). A successful campaign and intervention would have to utilize a model that does not make this assumption, thus enabling it to account for the extreme variation in similar groups of people in regards to health choices. For example, models such as the Diffusion of Innovations Theory make no mention of logic or rational being the basis for decision making. By doing so, such a model would allow campaign creators to construct an intervention that would acknowledge the, in many cases, complete lack of logic that human decision making is based upon.

The second major flaw of the HBM that must be addressed is the lack of inclusion of social factors as playing a major role as determinants of health behavior and decision making. For example, the HBM assumes that intention leads directly to behavior (2). Obviously, this is often untrue when put into the context of a real-life scenario. For example, many heroin addicts intend not to use again, but often they do, and sometimes for lengthy periods of time, all the while intending each hit to be the last. By addressing the importance of environmental, social, economic, and cultural factors in regards to health behavior, an anti-drug campaign would have a much greater chance of addressing the multi-factor causes of drug use. It is crucial that things such as social acceptance, peer pressure, and SES play a major role in the construct of the model being utilized (1,2).

One of the greatest challenges in creating a successful health campaign is the marketing strategy. In the 1980’s and ‘90’s, the “Just Say No” campaign portrayed illicit drug use as being prevalent in adolescent society. In doing so, the initiative normalized drug use and may have even led to increased usage rates (5,6). In order to avoid this phenomenon, an anti-drug campaign must take the opposite approach. Drug use and the desire to avoid using should be marketed as the norm. Teens need to see that the benefits, maturity, acceptance, and happiness that their peers have enjoyed and gained through other activities. Drug use should be shown as an outlier behavior that few teens engage in. By doing so, the campaign would be able to market drug use a socially unacceptable and taboo. This is in direct contrast with the “Just Say No” campaign which, by failing to engage in such a marketing campaign, may have demonstrated that a lack of drug use would be viewed as social suicide in adolescent groups. An example of just such a marketing campaign is the “Truth” initiative in which smoking is portrayed as being the activity of the minority and thus viewed as a negative behavior. By doing this, the campaign was able to show non-smokers as the non-conformist group rebelling against “Big Tobacco” (8). This is an important point. For many young people, adolescent years are difficult and many feel a need to rebel against their parent, society, etc. Often, drugs are the perfect outlet for this angst. A successful anti-drug campaign needs to account for these emotional needs in youth and demonstrate just that: a lack of drug use is a form of rebellion through strong and individual (a.k.a non-conformist) thinking and decision making.

All of this being said, it is still important, just as in the “Just Say No” campaign, that the market (TV, radio, popular culture, etc.) is saturated with the message. The flaw of this tactic with said campaign was not the actual high level of disbursement of the message, but rather the message that was being dispersed. While the “Just Say No” campaign failed, in part, because it normalized drug use, which led to a “boomerang” effect, it is still important to do the same, but with a relevant message normalizing a lack of dug use (6). Just as in the Diffusion of Innovation Theory, it is crucial that the early stages of the campaign are marked by high recognition of the message. Adolescents must encounter large “doses” of the alternate campaign, one in which positive, socially accepted alternatives to drug use are displayed. By doing so, teens will begin to desire the same acceptance, hope, love, and self-efficacy that is being demonstrated by their peers in the campaign.

The third obstacle and, by far, the most difficult to address is the effect that corporate America and their practices has on the youth of this country. As noted previously, organizations and industries, such as Hollywood and clothing manufacturers, spend billions of dollars each year researching the psychological factors that influence consumer’s decisions (9,10,13). By doing so, these organizations are able to create and market items that play into the subconscious desires of their target audience. For example, television shows and movies, such as Entourage and Blow, portray drug culture as a positive in many ways. The individuals highlighted in these pieces are shown to be flashy, wealthy, surrounded by women and, possibly most importantly, happy (9,10,13). When young people are constantly surrounded by messages extolling how drug use will lead friends, wealth, and happiness, it is no surprise that these fictitious messages begin to become reality to them. It is analogous to the idea that the more a person hears or tells a lie, the more it becomes a truth. While seeing such a message at a low rate may not influence behavior or influence choice, when constantly surrounded by the message, even though it may be rationally false, it can become incredibly difficult for it not to begin to shape a persons perception of the path to success.

The first step to changing these practices is through an increase in policy and public health spending. If this nation is to reduce drug use, it is imperative that politicians pass legislation prohibiting the rampant dissemination of the positive aspects of drug culture and allow public health organizations access to adequate levels of funding, so that they may compete with multi-billion dollar corporations. This legislation must also be multi-pronged. Because so many industries utilize drug culture as a means for amassing wealth, it will be necessary to target all. There must be regulations on the content that is permissible for the youth of the country. This is a very thing line to walk because blanket regulation is not possible, nor it should be. One of the hallmarks of this country is held in the First Amendment of the Constitution and the right to free speech. This must never be infringed upon. However, our citizens and politicians can demand that the distribution of such products can no longer go, so completely, unchecked. For example, to purchase clothing with drug references people under the age of 18 should have to have an adults consent to do so. To view certain shows with ratings acknowledging drug use and references, parents must take a more active role and “lock” these programs. In order to achieve the latter, high levels of marketing must be done to make parents aware of particular shows and movies. Simply showing parents in a commercial putting “parental controls” in place on their television is not enough because many parents are unaware of what to block. Because of this, a majority of the content that could be detrimental to their children slips through.

One of the most important keys to the success of a future anti-drug campaign, and any public health campaign, is that our public health organizations must begin to utilize the social and psychological sciences to a much greater degree. Organizations employ sociologists and psychologists to determine the social trends, individual desires, and needs of youth. By doing so, these organizations create products that are appealing to adolescents 13. How can public health practitioners hope to achieve similar results without employing the same methods? By including them in the construction of an anti-drug campaign, public health organizations would be able to tap into the same inherent, group level drivers of behavior. The result would be interventions that youth would find appealing and identify with. The “Just Say No” campaign is the perfect example of an initiative that failed to do this and because of this failure, their simple, catch-phrase message quickly became laughable to teens (5).

Finally, incentives must be created to drive corporations to create more health friendly products and services. Currently, organization’s financial gains often come at the expense of the health of lower class citizens. Corporations spend millions of dollars marketing their unhealthy products to groups in low SES areas of the country (10,11). For example, because of the higher rates of smoking and possible smokers in low SES areas, tobacco companies heavily market in those areas and also market products, such as menthol cigarettes, that are consumed at higher rates by those groups (12). In order to push corporations from producing and marketing unhealthy products to consumers, legislation must be passed that creates financial incentives to do so. For example, tax breaks for organizations that use and produce environmentally and health friendly products could be implemented. The situation is analogous to the current energy crisis. Because of the large financial gains of oil, organizations are unwilling to seek out alternative sources of energy, unless there are financial incentives, often tax breaks, to do so. By implementing a similar sense of urgency and benefit for corporations, a shift from an emphasis on health harming products to those that improve population health could be created.

It is unlikely that drug use will ever be completely removed from society, but an increase in use is possible. However, this will only be possible if policy and campaign creators are willing to look at the multi-dimensional factors that lead to drug use. Illicit drug use, especially in youth, can no longer be simply viewed as an activity for social deviants. Drug use occurs in all groups and for a variety of reasons, none of which is rational decision to begin using. Policy and funds, just as with any public health issue, must seek to attack the issue from a multitude of angles. For example, treating homelessness by simply removing people from the streets is not effective. They must also be provided with mental health and drug counseling, sustainable employment, food, etc. Just as with homelessness, drug abusers become as such because of a variety of reasons and need a variety of support outlets to regain sobriety and maintain it.


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3. Horrigan EA Jr. Liggett Group. Broin v. Philip Morris Companies Inc. : Circuit Court of the Eleventh Judicial Circuit, in and for Dade County, Florida, 1994:114




7. Hart, G.J. Williamson, L.M. Increase in HIV Sexual Risk Behavior in homosexual men in Scotland, 1996-2002: Prevention Failure? MRC Social and Public Health Sciences Unit, University of Glasgow, 4 Lilybank Gardens, Glasgow G12 8RZ, UK.

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9. Freudenberg, Nicholas. Galea, Sandro. The Impact of Corporate Practices on Health: Implications for Health Policy. Journal of Public Health Policy. 2008.

10. Lantz, P. Lynch, J. House, J, et al. Socioeconomic Disparities in Health Change in a Longitudinal Study of US Adults: The Role of Health-Risk Behaviors. Social Science Medicine 2001; 53.

11. Lu, Ning. Samuels, Michael. Wilson, Richard. SES Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account For? Journal of Health Care for the Poor and Underserved. 15. 2004: 618-630



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