Challenging Dogma - Fall 2008

Friday, December 12, 2008

The Problem, the Ploy and the Paralogism: Methamphetamine use in Montana and the Montana Meth Project- Lisa Sunner

Methamphetamine use is a growing public health issue in Montana, the total cost of which is in excess of $49 million dollars per year (1). Billionaire and part-time Montana resident Tom Siebel created The Montana Meth Project (MMP) to reduce first-time meth use through public service messaging, public policy, and community outreach (2). In Siebel’s words, the core message is “communicating the highly addictive nature of methamphetamine…’not even once’…don’t experiment with it, don’t try it, don’t even think about it because the consequences are just too deleterious.” He boasts that the project’s image and message are based on field research that informs the project in “[doing] business on the wavelength that kids like to do business”(3). Press releases call the ads the “edgiest [and] most intensive anti-drug campaign in the United States” and flaunts the theory- “…if we can change attitudes, we can change behavior” and “increasing perception of risk is critical in convincing teens to avoid meth”(4).

A 2007 report, and a follow-up in 2008, published by the Montana Attorney Generals Office in collaboration with the MMP, highlighted encouraging results of this campaign. Findings showed that attitudes are changing, public awareness is ‘very high’, and perceptions of a ‘great risk’ of the negative effects of meth use are increasing (5). Most importantly, meth use appears to be declining among teens and adults according to workplace drug testing statistics. However, these findings have been challenged- some sources accuse these data of being intentionally misrepresented (1,12). Objectively determining the efficacy of the MMP campaign is of prime importance because its price tag is high. Initially funded solely by Siebel the project has since earned public funds, 2 million in April 2007, $500,000 the following October and an additional $916,500 by December. Seibel is currently proposing a $40 million annual budget for the project from the state (1,6,7). Its escalating cost and questionable efficacy is making the campaign increasingly controversial and in need of evaluation.

To this end, the use of social science research can provide a relevant and objective perspective through which the Montana Meth Project can be examined. From a modern public health perspective, the Montana Meth Project does not represent the true power of public health programs and does not demonstrate encouraging progress in Montana’s meth prevention policy but instead a “glass-half-full” cover-up for mediocre progress. The program deserves commend for its commitment to solving the meth problem in Montana but it should also be educated about the true value of social science principles and not just a simplistic application of them. In particular the MMP needs to acknowledge that advertising alone cannot change behavior especially when the ads are based on outdated behavior change theory and scare tactics.

Advertising Alone Does Not Change Behavior:

Large anti-drug media blitz campaigns utilizing advertising theory, the idea that one can create a mass consumer by controlling the desire for a product, are unfortunately as addictive as the drugs that they aim to condemn even though very few have been successful in demonstrating behavior change. Advertisement makes a promise and support that promise through visual media. The MMP ads promise that trying meth, even once, will have ruinous consequences, a claim that is supported by dramatic images of methamphetamine users and their behavior. President Clinton spent billions on a similar anti-drug media blitz in the mid-90s that failed in raising awareness of the negative effects of drug use and also succumbed to fraud (8,9,11). Representative John Mica R-Florida, said of Clinton’s campaign “This…whole program of advertising and bringing awareness to the youth...about the perils of using drugs is not working as well as we would have hoped”(9). Social science research gives credibility to these assertions showing that reliance on advertising campaigns alone can increase awareness but have “little to no effect” on behavior (10).

Although, advertising theory, when properly informed and executed, has a role in improving the ability of public health campaigns to raise community awareness and concern however it most likely cannot, as the Montana Meth Project asserts, account for reduction in the numbers of methamphetamine users. The state attorney general’s report downplayed the increasingly exorbitant costs incurred by correctional services, hospitals, workers compensation and unemployment, numbers that don’t add up when considered as a whole. Workplace survey data on the prevalence of meth use are suspect because many serious users are likely unemployed and claims that meth-related admissions to treatment centers are decreasing are countered by the fact that incarceration rates are increasing (5). These misrepresentations illustrate that merely re-packaging of old methodology in flashy and expensive media does not make an approach efficacious. According to social scientist, Jeff Linkenbach at Montana State University “the notion that saturated public awareness equals success is a characteristic of a private advertising agency perspective…[which is] strikingly different from the broad-based approach required by a public health issue stemming from social and economic ills, not a mere lack of awareness”(11). Objective interpretation of the numbers in the report indicates that public health problems are closely related to factors such as law enforcement, health structures and public policy. Although advertising theory is a powerful social science tool for impacting attitudes it should not be applied without proper research and it should especially not be confused as a substitute for programs that more directly address behavior change and the multiplicity of contextual issues surrounding health.

The Theory of Planned Behavior is Outdated:

As the state suffers, the Montana Meth project clings to interventions based on behavior change models that are insufficient. Public Health professionals have, for years, argued that the concepts of traditional behavior change models, including the Theory of Reasoned Action (TRA) and the Theory of Planned Behavior (TPB), are incomplete frameworks for explaining health behavior (12). The TRA/TPB focus on three specific factors of behavior change: attitude, subjective norms, and behavioral intention (19). Ingham (1993) likened the habit of returning to traditional models to “squeez[ing] into clothes they….wore when they were much younger (and presumably thinner)…the results of such attempts [are] far from comfortable even if success were somehow achieved” (14). Drug epidemics are often the result of a combination of individual, social, cultural and structural level factors. These large-scale and difficult health issues are then forced by the majority of public health practitioners to squeeze into behavior models that are solely individual and lack mechanisms for conceptualizing the complexity of the problems. TRA/TPB are meant to be utilized as frameworks for creating public health interventions and not as strict methodology and the application of these models should be supplemented with a broader knowledge of public health theory.

For example, in contrast to the insight from the TRA/TPB models, people often act in un-healthful ways despite knowledge of the negative consequences, a concept completely ignored by the MMPs campaign. Acknowledging this phenomenon is essential to creating a feasible public health message. Florida’s truth campaign, which set the standard for successful advertising of anti-tobacco messages, was innovative because it specifically generated a message “other than ‘don’t’” (15). When surveyed, 90% of teenagers said that Truth’s message was about “not smoking [as] a way to express your independence”- a surprisingly nuanced and successfully transmitted message (16). In stark contrast, findings from the Meth Project, that were omitted from the main report, indicated that when surveyed, 40-50% of teenagers thought that the Meth Project’s advertisements exaggerated the risks associated with methamphetamine use and among Native Americans the number increased to 75% indicating that the message is over-exposed (1). Siebel’s “not even once” message is a traditional health message that has never worked- not even once. Exaggerated messages were trademarks of the campaigns of DARE, “Just Say No” and the “Above the Influence” campaign among others. The MMP’s uneducated adherence to outdated and historically unsuccessful behavior models blinds it to the impracticable and fatal assumptions these approaches make- an oversight which time and time again prove to be a fatal flaw in the effectiveness of drug prevention programs.

Scare Tactics Don’t Work:

Scare tactics and stigma theory are also well-known within social science research to be complex and only reasonably effective, tactics for behavior prevention (17). Scare tactic theory use threat and fear, two directly related components, to influence behavior. There are numerous theories describing the technical details as to how fear initiates behavior change, the main one being that the more fear one creates the more persuasive the argument (17). Erving Goffman explained stigma theory as the “public’s attitude toward a person who possesses an attribute that that falls short of societal expectations … [who is] reduced in our minds…to a tainted, discounted [person]”(20). The outcome of stigmatization is status loss and discrimination (20). The MMP campaign is almost completely made-up of scary images and messages that depict people acting in socially and morally undesirable ways as a consequence of using meth. Print ads created by the MMP include messages like “Bucks for Sex isn’t normal, but on Meth it is” with an unsettling image of a girl beneath a male and “No one thinks they’ll try to tear off their own skin. Meth will change that”, with an image of a blood stained razor blade in a bright white sink. Meth users are depicted as gaunt, pale, and covered in sores, making use of the stigma of an ugly appearance. The MMP relies heavily on scare tactics and stigma theory to enforce the belief that methamphetamine use is stigmatizing which the MMP hopes will prevent teenagers from trying meth.

Practically however, in the field, as Mona Sumner of the Rimrock Foundation, a drug and alcohol treatment program in Billings Montana, commented, “We haven’t been able to scare kids straight yet” (6). The MMP states that research on teenagers informed the campaign yet data collected by the MMP indicate that they may have missed the mark. The majority of teenagers in Montana feel that MMP ads exaggerate the impacts of meth and the advertisements have not been updated since they began in 2005 (1). Previous large-scale anti-drug campaigns had little effect on youth behavior; in fact, higher exposure to the campaign was associated with a weakening of social norms against illicit drugs (1,17). Worse, research indicates that scare tactics can become counter-productive if the target audience does not possess the self-efficacy to avert the threat (2,17). The potential for backfire of the MMP, especially in the economically depressed and rural areas of Montana where self-efficacy may be very low, should not be ignored. A prevention expert at Montana State University, Jeff Linkenbach, calls scare tactics “health terrorism” and adds that: “…we erode our credibility with our audience because their experience doesn’t out [the advertisements] reality” (2). Aggressively portraying methamphetamine users as outcasts of society may have counter-productive effects the self-efficacy of users, society’s attitudes towards users, and efforts to improve the meth problem. Again, relying on an un-informed application of scare-tactics and stigmatization methods can undermine the progress of anti-meth campaigns like the MMP.

Immediate Improvements and Future Directions:

The Montana Meth Project should not abandon ship in its endeavor to take action in controlling Montana’s Methamphetamine problem. The project is a pioneer in implementing state-level approaches to public health problems and it is auspicious enough to possess the capital to carry influence. Nevertheless, the lack of education of the MMP in the social sciences and its naivety to the complexity of the factors influencing Montana’s meth epidemic is undermining an otherwise valiant effort. The meth project must recognize that advertising alone, no matter how innovative, will not change behavior. The powers behind the campaign should consider extending its reliance on behavioral theory beyond traditional and simplified applications and instead utilize the methodologies that various divisions of social science have to offer.

The bottom line is that behavior does not occur in a vacuum. Mielewczyk & Willig assert regarding smoking that “…what if ‘smoking’ as pure ‘behavior’ does not exist? What if ‘smoking’ does not, in fact, manifest itself as a distinct, isolated ‘behavior’...what appears to be the same behavioral sequence (e.g. smoking) may form part of a variety of different social and/or cultural practices” (2). This same existential line of questioning and contextualizing of the problem is the critical missing piece of the Montana Meth Project’s approach. Methamphetamine use, and most drug problems, function not as an isolated behavior but instead as part of a “variety of different social and/or cultural practices” and only when it is treated as such will prevention efforts make progress. Immediate improvement of the efficacy of the Montana Meth Project requires integrating social science principles more effectively into the current approaches used by the MMP however; a truly comprehensive campaign would have to also consider and aim to address the larger environmental and structural factors that exacerbate the situation including the effects of policy, rural environment and socio-economics.

Immediately Improving the MMPs Advertisements:

An improved MMP advertising strategy should invest time and money in researching a product and message. In-depth focus groups with the target population in Montana should determine how to transform meth into a product that can be realistically represented and challenged using targeted and pertinent messages- one that actually matters to the intended population. The MMP’s current message of ’not even once’ is not effective and also contradicts the populations own experiences thus undermining its impact. Funds for MMP advertising should be re-routed into in-depth research, and obviously not the kind the project has claimed to have already done. Maintaining the advertising framework, research could suggest that the most effective billboard message is “Meth ruins Montana” or “Only 10% of meth addicts have jobs that pay at least minimum wage”. Although not traditional anti-drug messages, open-mindedness and creativity are critical components allowing the social science principles of advertising, anthropology and psychology to work- the lack of pre-existing attitudes or concepts is essential.

Implementing sufficient background research would translate the MMP into a more successful advertising campaign because changing health behaviors depends on creating the correct product, advertising appropriate messages (28). The MMP’s product is meth use and the promise is negative consequences. In contrast, the Truth campaign, realized manipulation by corporations, not the dangers of tobacco use, was the “product” and “truth” the realistic message that would change young adult behavior. Ground-level research drawing from social science principles including, marketing: how to appropriately and successfully create and sell a product, anthropology: understanding the “native point of view” of a particular society and psychology: understanding the developmental characteristics of young adults, were successfully applied with impressive results (16,22,23). Investing in getting to know the audience through social science methodologies resulted in a novel product, message and an emphasis on honesty and ultimately, a successful advertising intervention. Pioneers of this type of approach already exist in response to methamphetamine epidemics. The Drug Policy Alliance New Mexico (DPANM) has adopted this approach to its meth epidemic by creating a, now federally funded, youth program to promote science based information and youth participation (27). The program includes a social marketing campaign including media and a discussion guide about methamphetamines. By broadening the scope of the MMP from the surface advertising tactics of product and promise to include social science tactics of marketing, anthropology and psychology the messages will more likely have bang for the buck.

Immediately Improving the MMP’s Theoretical Approach:

An improved intervention wouldn’t rely solely on messages emphasizing individual-level non-contextualized models of behavior but would recognize that higher-level factors (SES, education, environment) influence individual behaviors (23). The MMP should allocate funds to research these associations, specifically within Montana, in order to understand the meth use risk profile and design matching interventions. In the meantime, MMP advertisements could include information on local resource centers, fund treatment centers in very rural areas with high prevalence or assign a task force to visit schools and encourage students through mentorship to finish high school. Each of these methods acknowledge the multiple “other” factors that are related to drug use. These interventions could take numerous forms (advertisement, public policy), but most importantly, the MMP, and public health in general, must shift its focus from individual level constructs and instead adopt a multi-level viewpoint, that will better achieve public health aims, as the lens through which the entire epidemic is understood.

Assuming that public health issues can be explained and addressed using individual level frameworks and overlooking societal, environmental, cultural and structural factors is an underlying problem within Public Health. A growing body of research is changing this paradigm. This research has found that factors like race and SES independently affect disease outcomes. Similarly, research suggests that race, living in rural areas and low SES are associated with meth use (23,24,25). Some states have already adopted approaches that function on multiple levels. In 2007, Arizona created community coalitions and a state task force to develop strategies to address meth. This culminated in a summit and the adoption of 23 specific recommendations in numerous domains including: law enforcement and prosecution, treatment, prevention and education, child welfare, courts probation and parole, environmental cleanup, media and public awareness (of which a spin-off of the MMP is used), and faith based community and non-profit organizations (26). This kind of method, based on ground-level and site-specific research, better addresses the specific problems that lead to a drug epidemic. In California, Proposition 36 required drug treatment for nonviolent drug possession offenses instead of jail. (21) Over 19,000 meth users enter treatment under this program and resulted in a savings of $2.50 per dollar spent on the program (21). Such solutions save taxpayer money, reduce the burden on the legal system and take care of the individual making it an ideal example of a highly successful multi-level solution to a multi-level problem.

Immediately Improving the MMP’s Reliance on Scare Tactics:

The Montana Meth Project could further improve its advertisements by reducing the dramatic and mis-representative scare-tactics in favor of creating messages that present realistic messages about meth use and positive messages about meth non-use. Prevention does not need to be a message of “don’t- because you’ll die,...ugly” and can instead convey the advertised message “Hey- I’ve tried it, it really wasn’t that great and I stopped because I have plans to someone other than an addict.” Psychology, specifically positive psychology and operant conditioning provide a social science basis for the idea that positive messages and positive reinforcement are effective for increasing desirable behaviors (29). In addition, the benefits in terms of influence gained by presenting messages that match real-life experience are also maintained. The negative effects of methamphetamines should not be ignored- scare tactics can be helpful- however exclusive focus on these dramatized negative messages mis-represent the truth in a very large-scale and visible way (a.k.a. on a billboard) which undermines the message of the entire multi-billion dollar campaign (2,17). Not to be construed as “putting a positive spin on drug use”- the MMP should re-consider the effectiveness of using scare-tactics alone given all that is known in the social sciences about behavior.

Unfortunately, scare tactics are one of the most commonly used methods to influence health behavior, sometimes coined “health terrorism” (2,17). However, the current trend in health education is changing towards programs that focus instead on critical decision making, objectivity and realism- as seen in sex education “if you are going to have sex, use a condom” or tobacco use “if you use cigarettes know that the industry is manipulating you”. For the MMP, the counter-productive results of scare tactics are underscored by the fact that the majority of teenagers in Montana feel that MMP ads exaggerate the impacts of meth (1). In addition, if the target audience do not possess the self-efficacy to avert the risk, for example because of lack of local resources or depressed economy, scare tactics may backlash (2,17). Montana, especially in the east, is economically depressed and rural, two environmental factors that have been associated with susceptibility to drug use and should thus be obstacles that should be addressed by anti-drug campaigns (25). Utah decided to approach its meth epidemic by airing commercials that focus on the successful recovery of previous users with messages about how recovery has changed their lives for the better (21). Because, relying on an un-informed application of scare-tactics and stigmatization can undermine the progress of anti-meth campaigns like the MMP, shifting away from scare-tactic based interventions circumvent the issues with both its lack of efficacy and the potential backlash.

The Big Picture:

Managing the meth epidemic in Montana, and nationwide, is not an uncomplicated task. Interventions like the MMP will not, single-handedly, create change however that is not to say that such campaigns are not a vital part of an overall successful approach. The MMP is a pioneer program that, with some improvements, can significantly increase its impact. However, and most importantly, the MMP and the state of Montana should work together to approach the Methamphetamine epidemic with creative and multi-level programs that will effectively address the true nature of the problem.

References:

[1] Erceg-Hurn, D.M. Drugs, Money, and Graphic Ads: A Critical Review of the Montana Meth Project Preventative Science, 2008; 9:256-263.

2 Montana Meth Project. Found at: http://www.montanameth.org.

3 Goldenstein, S. (Speaker). Bringing Montana’s Anti-Meth Program to Arizona. Phoenix, Arizona: National Public Radio 2006; http://kjzz.org/news/arizona/archives/200606

4 Edgy Montana TV Ads Target Methamphetamines CQ Researcher 6/2/2006

5 Montana Department of Justice. Methamphetamine in Montana: A Follow-Up Report on Trends and Progress 2006.

6 Suderman, A. Despite criticism, meth funds advance. The Associated Press 2007. Found at: http://www.montanastandard.com/articles/2007/04/03/state/hjjcjfjgjihbec.txt

7 Funding secured for the Montana Meth Project. Found at: http://www.methproject.org/documents/6-29-07_The_Associated_Press.pdf

8 Francine, K. Clintons antidrug plan: $2 billion ad blitz. Christian Science Monitor, 1998; 90:157, 1.

9 Lewandowski, B. Mismanagment alleged in national anti-drug ad campaign CNN 10/25/2000. Found at: http://archives.cnn.com/2000/ALLPOLITICS/stories/10/05/drug.office/index.html

10 Brickmayer, J. et al. Prevention of Methamphetamine Abuse: can existing evidence inform community prevention? Journal of Drug Education, 2008; 38:2. 147-165.

11 McQuillan, J. What’s wrong with this picture?: Why the Montana Meth Project isn’t all it’s cranked up to be. The Missoula Independent, 8/3/2006. Found at: http://www.missoulanews.com/index.cfm?do=article.details&id=533B1A41-2BF4-55D0-F1FB64E83ABDBD8B&oID=333B82E9-DC2F-69B1-92B9C55336008A12

12 Ogden, J. Some problems with social cognition models: a pragmatic and conceptual analysis. Health Psychology, 2003; 22:424-428.

14 Mielewczyk, F., Willig, C. Old clothes and an older look. Theory and Psychology, 2007; 17: 811-837.

15 Hicks, J.J. The strategy behind Florida’s “truth” campaign. Tobacco Control, 2001;10:3-5.

16 Hersey, H.C., et al. The theory of “Truth”: how counterindustry media campaigns affect smoking among teens. Health Psychology, 2005;24:22-31.

17 Witte, K., Allen, M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Education and Behavior, 2000;27:591-615.

18 Wood, E., & Kerr. T. Methamphetamine strategy requires evaluations. CMAJ, 2008;179: 677.

19 Fishbein, M., & Ajzen, I. Belief, attitude, intention, and behavior: an introduction to theory and research. 1975, Reading, MA: Addison Wesley.

20 Stigma & HIV/AIDS: a review of the literature. Found at: http://hab.hrsa.gov/publications/stigma/stigma_defined.htm

21 Piper, B. (2008) A Four-Pillars Approach to Methamphetamine: Policies for Effective Drug Prevention, Treatment, Policing and Harm Reduction. Found at: http://www.drugpolicy.org/docUploads/FourPillarsMethamphetamine.pdf

22- Hahn, RA. Sickness and Healing: An Anthropological Perspective. Chapter 5: Anthropology and epidemiology: One logic or two? (Chapter 5). New Haven, CT: Yale University Press, 1995, 99-128.

23- Shrem, MT., Halkitis, P.N. Methamphetamine Abuse in the United States: Contextual, Psychological and Sociological Considerations. Journal of Health Psychology, 2008, 13: 669.

24- Iritani, J., Hallfors, D.D., Bauer, D.J. Crystal Methamphetamine Use among Young Adults in the USA. Addiction, 2007,102: 1102-1113.

25- Lambert, D., Gale, J.A., Hartley, D. Substance Abuse by Youth and Young Adults in Rural America. The Journal of Rural Health, 2008,24:221-228.

26- Addressing the Methamphetamine Crisis in Arizona. Found at: http://gocyf.az.gov/SAP/documents/050407_MethFullReport.pdf

27- Drug Policy Alliance Network. DPA Creates Statewide Methamphetamine Education Program in New Mexico. Found at: http://www.drugpolicy.org/about/accomplish/#nmmeth

28- The Copy Workshop – strategy seminar. Found at: http://www.adbuzz.com/OLD/Strategy.pdf

29- Seligman, M.E.P., Csikszentmihalyi, M. Positive Psychology: An Introduction. American Psychologist, 2000, 55:5-14. Found at: http://www.ppc.sas.upenn.edu/ppintroarticle.pdf

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