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Use and Abuse of Media

At the Intersection of Health, Health Care and Policy Cite this article as: W DeJong and J A Winsten The use of mass media in substance abuse prevention Health Affairs, 9, no. 2 (1990):30-46 doi: 10. 1377/hlthaff. 9. 2. 30 The online version of this article, along with updated information and services, is available at: http://content. healthaffairs. org/content/9/2/30. citati on For Reprints, Links & Permissions: http://healthaffairs. org/1340_reprint s. hp E-mail Alerts : http://content. healthaffairs. org/subscriptions/etoc. dt l To Subscribe: http://content. healthaffairs. org/subscriptions/online. shtml Not for commercial use or unauthorized distribution Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 1990 by Project HOPE – The People-to-People Health Foundation.

As provided by United States copyright law (Title 17, U. S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved. Not for commercial use or unauthorized distribution Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest

THE USE OF MASS MEDIA IN SUBSTANCE ABUSE PREVENTION by William DeJong and Jay A. Winsten Prologue: Over the past three decades, the American public has been heavily influenced by the power of television and its ability to shape society. Public health officials’ initial optimism about the positive influence of mass media on society led to disappointment and skepticism. That has now been replaced by a sophisticated understanding of the important role media can play when properly executed.

In this article, William DeJong and Jay Winsten explore the use of mass media in sending messages about preventing substance abuse, especially among American youth. They find that public health advocates, while producing increasingly sophisticated media campaigns, still have much to learn from the successes of the commercial sector in harnessing the power of the mass media to convince people to change behavior. Here they present recommendations for the design of future media campaigns.

DeJong, who received his doctorate in social psychology from Stanford University, was director of research at the Center for Health Communication, in the Harvard School of Public Health, at the time this study was completed. In the spring of 1990, DeJong left Harvard to work as an independent consultant in health communications. Winsten, who holds a doctorate in molecular biology from The Johns Hopkins University, is director of the Center for Health Communication, formerly known as the Office of Health Policy Information.

The center is recognized nationally as a resource for both policymakers and journalists. Winsten also directs the Harvard Alcohol Project, which the center launched in December 1987. Its objective is to elicit the cooperation of television writers in reinforcing the “designated driver” concept as a social norm. Over the past two television seasons, dialogue consistent with the project’s objectives appeared in eighty television episodes on major networks. Winsten last contributed to Health Affairs in Spring 1985, presenting results of a study of science and the media.

Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE 31 P ublic health educators have used the mass media as a primary vehicle for messages against substance abuse for the past twenty five years. In this article, we explore how the mass media can be used more effectively to prevent substance abuse, especially among preteens and adolescents. We begin by briefly describing what can be accomplished in health promotion through the strategic use of mass media.

Next we offer detailed recommendations for the design and implementation of future media campaigns to prevent substance abuse. These recommendations are based on: (1) our newly completed two-year study of previous mass media campaigns and innovative practices in advertising, marketing, and public relations; and (2) our experience in implementing the Harvard Alcohol Project, a research-based media campaign conducted in collaboration with the nation’s broadcast, advertising, and entertainment industries.

What Can Mass Media Campaigns Accomplish In Health Promotion? When the broadcast media emerged as a major force, many public health advocates assumed that the presentation of factual information through public communication campaigns would automatically change attitudes and lead to more healthful behavior. Subsequently, when several such campaigns produced disappointing results, this boundless optimism was replaced by the highly pessimistic view that mass media campaigns to change behavior are doomed to failure.

Investigators recognized that a campaign could reinforce existing behavior, but this was viewed as the most that could be achieved. Pessimists noted that the apparent success of commercial advertising had raised unrealistic expectations about the potential of mass media to change behavior. In fact, there are basic differences in the goals of commercial advertising and public health campaigns. Commercial advertising seldom is designed to bring about new attitudes or patterns of behavior; rather, it intends to give direction to already existing preferences.

In contrast, public health campaigns seek fundamental changes in health-related behavior, with the benefits of such changes often being delayed and intangible. Moreover, the very people who would respond to a public health campaign may already be making the desired changes, 1 leaving a residual target group that is more difficult to persuade. While these obstacles must be acknowledged, three counterarguments can be raised.

First, public health advocates have too often relied on short-term mass media campaigns, overlooking the fact that attitude and behavior change is “usually characterized by a slow process of erosion and 2 accretion rather than by one of sudden upheaval and conversion. ” Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest 32 HEALTH AFFAIRS | Summer 1990 Second, researchers too often focus on proportional success rates without taking into account the large audience that mass media can have.

A more suitable criterion is cost-effectiveness, by which the success of each health promotion effort is gauged relative to its cost per unit. Third, within the past fifteen years, several community-level studies have demonstrated that health promotion campaigns relying primarily 3 on mass media can be highly successfu1. Such campaigns more often succeed when they address an issue of ongoing public concern and incorporate both the “consumer” orientation of commercial marketing 4 and research-based principles of behavior change.

In retrospect, it is evident that many campaigns whose failure was regarded as evidence of 5 the mass media’s limited potential were seriously flawed. Researchers have identified these key elements for successful campaigns: (1) specification of a well-defined target audience; (2) formative research to understand the target audience and pretest campaign materials; (3) messages that build from the audience’s current knowledge and satisfy its preexisting needs and motives; (4) a media plan to guarantee exposure to the campaign; (5) procedures for evaluating progress; and (6) a long-term commitment.

A better understanding of how behavior change occurs makes evident that few mass media campaigns can be expected to bring about immediate changes in behavior. More realistically, organizers need to develop a long-term strategic plan that divides their campaign into distinct phases, each with measurable objectives whose achievement will directly facilitate or otherwise set the stage for behavior change.

Such objectives might be to (1) establish a health problem as a priority concern; (2) increase knowledge and change beliefs that impede the adoption of healthpromoting attitudes and behavior; (3) motivate change by demonstrating the personal and social benefits of the desired behavior; (4) teach new behavioral skills; (5) demonstrate how various barriers to behavior change can be overcome; (6) teach self-management techniques for sustaining change; and (7) provide supports for maintaining change by stimulating interpersonal communication; the support of opinion lead6 ers, pouses, or peers; and broad changes in perceived social norms. Mass media campaigns can also enhance the formation and effective implementation of school- or community-based programs by recruiting new program participants and community volunteers; announcing the availability of self-help materials and program activities; and reinforcing 7 the face-to-face instruction provided by these programs. Campaigns can also stimulate further information seeking by promoting telephone hotlines or the availability of pamphlets and brochures.

Finally, mass media campaigns can generate and publicize important changes in public Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE 33 policy that advance health-related goals, such as the use of “sobriety checkpoints” to deter alcohol-impaired driving. Policy reform often can lead to environmental, institutional, and social changes that foster, sup port, and sustain the efforts of individuals to alter their behavior. Although recent campaigns show increasing sophistication, there is still vast room for improvement.

If the public health community knew too little in the 1970s about modern advertising strategies, today it knows too little about public relations. Health advocates are just now discovering a variety of public relations strategies that are increasingly used in the commercial sector (for example, generating high-visibility news coverage, securing “product placement” in films, sponsoring sports and cultural events, and publishing targeted “lifestyle” magazines). The limits of what public health advocates can accomplish through mass communication are still being tested.

The Harvard Alcohol Project The Harvard Alcohol Project, a research-based media campaign conducted in collaboration with the television industry, illustrates what a public health campaign can accomplish through a mix of state-of-the-art advertising and public relations strategies. Launched nationally in December 1987 by the Center for Health Communication of the Harvard School of Public Health, the project’s goal is to encourage the use of designated drivers and to promote a fundamental shift in U. S. social orms related to driving after drinking. Fifteen Hollywood studios are participating along with the ABC, CBS, and NBC television networks and leading advertising agencies. The project sought successfully to have television writers introduce dialogue into scripts of top-rated television programs to reinforce an emerging social norm that the driver does not drink. The Harvard staff met with over 160 television producers, writers, and studio executives to elicit their help. The response from the creative community was overwhelmingly favorable.

The Harvard Alcohol Project won strong endorsements from the boards of the Writers Guild of America, West and the Screen Actors Guild. During the 1988–1989 and 1989–1990 television seasons, dialogue consonant with the Harvard Alcohol Project’s goal of preventing driving after drinking appeared in eighty television episodes. In response to the project’s request, ABC, CBS, and NBC produced and sponsored public service announcements (PSAs) promoting the designated driver concept. ABC’s campaign began in December 1987; CBS and NBC followed suit in December 1988.

This represents the first Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest 34 HEALTH AFFAIRS | Summer 1990 time that the three networks produced and sponsored simultaneous prime-time campaigns focused on a single message or theme. Among the three networks, designated driver spots were broadcast approximately twenty times per week during the December 1988 holiday season, mostly during prime time. Importantly, all three networks continued to air these spots frequently during 1989 and 1990.

News coverage generated by the Harvard Alcohol Project’s campaign also contributed significantly to the public’s awareness and acceptance of the designated driver concept. To assist the networks, the Harvard Alcohol Project presented message concepts based on a review of the literature and on formative research conducted in collaboration with advertising researchers at Saatchi and Saatchi DFS Compton. The Harvard Alcohol Project’s recommendations emphasized that messages must avoid encouraging the expectation that the driver’s companions will drink. A PSA produced and sponsored by ABC demonstrates how simply this can be done.

In that promotional spot, a man indicates that appointing his friend as designated driver means that “if I want to drink tonight, I can. ” To which his wife responds, “Or you don’t have to. ” Tracking data collected in February 1989 by the Gallup Organization on behalf of the Harvard Alcohol Project indicated that, following the initiation of the three networks’ public service campaigns, 78 percent of U. S. adults who attend social functions where alcohol is served had seen a television message promoting the designated driver concept during the previous three months.

Gallup also reported a sharp increase in reported use of designated drivers. In September 1988, three months prior to the “blitz” campaign of entertainment dialogue and PSAs on all three networks and nine months after ABC began airing prime-time PSAs, 62 percent of Gallup respondents who attend social functions where alcohol is served said that they and their friends used a designated driver all or most of the time. In early 1989, following the holiday “blitz,” this percentage rose to 66 percent, and by June 1989, to 72 percent, a statistically significant increase compared to the September 1988 figure.

This overall upsurge was largely caused by an increased response among males, whose reported use of designated drivers increased from 54 percent in September 1988 to 71 percent by June 1989. These data are likely to be biased by the respondents’ desire to give a socially acceptable answer. Nevertheless, even if the sharp trend in the data reflects only a shift in the public perception of what the socially acceptable answer is, that is an important first step in the longer-term process of changing social norms regarding driving after drinking.

Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE Recommendations For Mass Media Campaigns 35 We offer the following recommendations on the informed belief that mass media campaigns are a critical component of the nation’s long-term effort to combat substance abuse. Such campaigns will be directed to a variety of target audiences, including both adults and youth. Of particular concern to s are prevention campaigns directed to preteens and teens, who must be reached as they begin to make decisions about their own experimentation with and use of alcohol, tobacco, and other substances. Before presenting our recommendations, we emphasize two essential points. First, because of limited financial resources, what health advocates can achieve is greatly determined by their network of contacts among local or national leaders in the entertainment, public relations, and advertising industries and in the news media.

Second, campaign organizers should link up with local advocacy groups and school- or community based programs. Ideally, messages from the mass media campaign and these various programs should be guided by a common strategy. Campaign Planning A key step in developing a new campaign is the use of qualitative research to identify and analyze various subgroups defined by demographic, psychological, or problem-relevant characteristics that could be targeted by the campaign. Focus group interviewing is the method most 8 frequently used for this purpose, since it is both inexpensive and quick.

This technique’s principal limitation is that respondents are not selected at random and may not be representative of the target audience as a whole. Moreover, such a group may be inappropriate for highly charged or embarrassing topics. An alternative method is to conduct private, oneon-one interviews using a trained interviewer or clinical psychologist. This approach has two key advantages. First, respondents are usually more willing to share highly personal information in a private interview. Furthermore, there are no group dynamics to bias the subjects’ responses.

On the negative side, this approach is more expensive and time-consuming than focus groups, and, again, respondents are not necessarily representative of the target audience as a whole. Qualitative research is valued for the insights it can generate. Marketing researchers urge that it be followed by surveys and other quantitative methods to test the hypotheses generated. Although time or financial limits might make it tempting to skip this step, findings from qualitative research should be validated using more rigorous methods whenever possible. Downloaded from content. ealthaffairs. org by Health Affairs on October 18, 2011 by guest 36 HEALTH AFFAIRS | Summer 1990 Campaign Focus Preteens. Large numbers of youth begin to use alcohol, tobacco, and 9 marijuana in junior high school; some begin even earlier. In response, school-based programs now highlight the “exit” grades of elementary school (typically grades five and six), to reinforce students’ intentions not to use alcohol, tobacco, or drugs and to teach specific skills for coping with social pressures to do so. Mass media campaigns should follow suit by focusing on this preteen age group.

For preteens, the emphasis should be on “gateway” substances whose use comes earlier in the typical sequence of substance use–specifically, 10 tobacco, alcohol, and marijuana. Experimentation with alcohol and tobacco, both of which are legally available to adults, will likely continue to be a rite of passage for many American youth. The longer such experimentation can be postponed, however, the less likely a young person is to 11 move on to illegal drugs. Adolescents. With a comprehensive prevention program, the intensive lessons given to preteens are reinforced during junior high and high school.

In the same way, “reminder” campaigns through mass media should be phased in as the first cohort of preteens reached by the initial media campaign moves into adolescence. Some situations do call for a mass media campaign focused primarily on adolescents rather than preteens. Two examples stand out. First, in the case of impaired-driving prevention, messages targeted to teens continue to be especially important. Second, when there are widespread misconceptions among teens about the dangers of a particular drug, accurate factual information must be communicated immediately.

High-risk youth. To meet the needs of high-risk youth, mass media campaigns should increase public awareness of the broader social context in which chronic substance abuse occurs and promote debate on the cost, availability, and promotion of alcohol and tobacco; policy changes that might discourage substance use by adolescents; and the development and funding of clinical and social programs that provide direct interventions. The target of such an agenda-setting campaign may be policymakers, community opinion leaders, particular institutions and organizations, or 12 the public at large.

Some investigators have urged that mass media campaigns be used to reach high-risk youth directly. In general, however, we do not endorse this approach, especially for older, high-risk youth. Because a person’s self-concept is a product of life experience; it is extremely difficult to change without direct, intensive intervention. Hence, we would expect any mass media campaign designed to redress the underlying personal Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE 7 and societal causes of chronic substance abuse to have negligible impact. Campaign Messages (1) Mass media campaigns should address the existing knowledge and beliefs of the target audience that impede adoption of the desired behavior. These beliefs concern the person’s perceived susceptibility to the health problem and its perceived seriousness; the effectiveness of a given course of action in reducing the threat; and the perceived barriers to executing that behavior (for example, financial cost, inconvenience, pain).

Also important is the person’s perception of popular opinion and normative expectations for behavior. (2) Mass media campaigns should communicate incentives or benefits for adopting the desired behavior that build on the existing motives, needs, and values of the target group. Commercial marketers know that people are more likely to remember messages that meet their needs or support values in which they believe. Accordingly, product advertising often plays on people’s insecurities, desires, and aspirations and then 13 offers the product or service as a means of meeting those needs.

Health advocates have often focused too narrowly on motivating people to change their behavior for the sake of their health rather than in response to universal and potent human desires and motives. (3) The target audience’s attention should be drawn to immediate, high-probability consequences of behavior, especially in campaigns directed to preteens and adolescents. Young. people should be taught the facts about the long-term effects of substance use, especially when there is misinformation about the addictive potential and long-term effects of a particular drug, as with cocaine in the early 1980s.

But while awareness of long-term risks will dissuade many youth from substance use, the deterrent effect will be far from universal. First, even when the credibility of information is accepted, young people might question its applicability to them. Second, for most young people, substance use is occasional, not daily, and typically occurs in social situations. As a result, they might overestimate their own long-term capacity to control the extent of their substance use. Third, from their own observations, they may conclude that even regular use does not necessarily result in severe health consequences.

This uncertainty can be an opening for denial. The key is to focus on more immediate consequences. In dissuading young people from smoking, for example, an emphasis on risks of heart disease and cancer has little apparent effect in delaying experimentation or reducing use. With greater impact, prevention programs now emphaDownloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest 38 HEALTH AFFAIRS | Summer 1990 size immediately noticeable and more certain effects, including discoloration of the teeth, body and mouth odor, and the deterioration of physical performance.

This strategy is also reflected in a current public service campaign, “Nic, A Teen,” by the federal Office on Smoking and Health, which portrays smoking as sexually unattractive to teens. (4) The use of emotionally arousing fear appeals should be approached with great caution. Although focus groups typically rate strong fear appeals as highly motivating and effective, most experts have concluded 14 that such appeals are difficult to execute properly and rarely succeed. If the appeal is too mild, or if the threat seems too remote, people will not be motivated by it.

But if the appeal is too strong, or if the behavioral prescription is inadequate to alleviate the fear, people might tune out the message, deny its validity, or derogate the source’s credibility. Unfortunately, it is difficult to anticipate and control the level of fear that will be generated by a campaign or to judge whether the prescribed action will be adequate to offset it. Therefore, there is substantial risk that a fear appeal will backfire, making the problem behavior even more resistant to change.

Nevertheless, if the target audience has low awareness, a fear appeal might serve to raise concern about the problem and thereby motivate action. Thus, early cocaine campaigns included highly arousing fear messages because of widespread ignorance about cocaine’s addictive quality and potential for killing even first-time users. But if the target audience has high awareness, other means of influencing their behavior, such as modeling appropriate skills and demonstrating the benefits of nonuse, are essential. 5) Campaign messages directed to preteens and adolescents should capitalize on important themes in the development of adolescent identity, including freedom, autonomy, and peer group acceptance. In moving from childhood to adulthood, youth are in the process of developing an identity that is distinct from that of their parents. They therefore seek independence and autonomy, often manifested as a rejection of parental 15 values and a thwarting of authority and conventional society. Maintaining meaningful connections with a peer group is also a key element in a young person’s normal development.

Because group acceptance is of utmost importance, it can be an extremely powerful motivator of behavior and a primary influence on the self-definition of its members. For many young people today, substance use is a shared activity that contributes to group members’ common definition of self, a dynamic that can overwhelm any concerns about long-term health risks. Recognizing the important role of social influences, many schools provide so-called “peer resistance” training to young people before they enter junior high Downloaded from content. healthaffairs. rg by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE 39 school. What is new about this approach is its focus on the specific behavior of refusing offers from peers to try alcohol, tobacco, or drugs. Similarly, mass media campaigns aimed at preteens and adolescents should focus on the important role of social pressure, both direct and indirect, from peers, family, and the media; ways in which tobacco and beer advertisers try to persuade people to use their product; and alternative ways of refusing various offers of alcohol, tobacco, and drugs from peers and family members.

Such campaigns should also encourage young people to select a peer group that does not use these substances and illustrate peer approval for refusing or stopping drug use. These campaigns can also present peer role models–older adolescents who are independent, mature, and popular without drinking, smoking, or using drugs. This is critical, for in trying to channel young people’s natural rebelliousness into a resistance against peer pressure, campaigns must also ensure that young people are presented with options that meet 16 their needs for peer acceptance and independence from adult authority. 6) When communicating substance abuse messages to preteens and adolescents, using peer models as campaign spokespersons is preferable to using adults. Several controlled experiments have explored various traits of a messenger that can enhance persuasiveness. One such trait is the spokesperson’s trustworthiness. Typically, this characteristic is apprehended when the source’s life experience or values are seen as similar and 17 no ulterior motives are apparent. Another important trait is credibility. This can emerge from perceptions of the source’s competence and exper18 tise or general attractiveness.

Because of the documented importance of credibility, it is tempting to rely on scientific experts or other adults to deliver substance abuse messages. But adolescents who see themselves as relatively sophisticated about drugs will view others, especially adults, as less credible. (7) The use of celebrity spokespersons must be approached cautiously. A celebrity is often used in public service campaigns to draw attention or 19 to show that the cause is “in fashion. ” A celebrity’s involvement will typically include PSAs, publicity events, promotional tours, and fundraisers.

Celebrities should be selected whose public image fits the underlying strategy of the campaign, not just because they are available. But there are risks to using this strategy. First, the message may be overwhelmed by the celebrity’s presence and ultimately forgotten. Second, celebrities can quickly lose their luster or suddenly become newsworthy in ways that undermine the campaign. Third, adolescents often view celebrity messages skeptically, suspecting that the celebrities either 20 were paid to deliver the message or are themselves substance users. (8) Campaigns should explore the use of “image” or “lifestyle” adDownloaded from content. ealthaffairs. org by Health Affairs on October 18, 2011 by guest 40 HEALTH AFFAIRS | Summer 1990 vertising to promote an active and healthy lifestyle that excludes substance use. Image advertising seeks to evoke an emotional response that can catalyze later changes in behavior. One such strategy is to associate a product with stories, themes, or characters that tap into cultural myths. By evoking the culture’s ideals and giving expression to profound and universal emotions, these ads communicate the essence of those people 21 who use the product and their place in the world.

The quintessential example of such advertising is the campaign for Marlboro cigarettes, which exploits the American myth of the “frontier” in its portrayals of the “Marlboro man. ” Simon Chapman and Gary Egger assert that antismoking appeals directed at preteens and adolescents also need to use 22 “image” advertising. One strategy they suggest is to present a mythical character with whom this group can identify, one who demonstrates his or her power and independence by choosing not to smoke. Campaign Implementation Pretesting.

Pretesting must be conducted to ensure that the campaign materials are appropriate for and appeal to the target group. Because of the many complex interactions among source, message, channel variables, audience, and the specific issue at hand, choosing the best design 23 option is extremely difficult. Even when the best approach seems evident, campaign planners must remember that no “rule” of advertising works all the time and that widely successful strategies can be rendered ineffective through overuse.

Past campaigns and research findings should be used, therefore, not as a blueprint, but as a source of ideas–ideas that need to be pretested within the context of a new campaign. Thus, with each step of campaign development, planners should conduct formative research to double-check the appropriateness and potential effectiveness of all materials. Focus group interviewing is the principal method used to evaluate message concepts (brief summaries of key benefits or “promises”), preliminary media executions, and finished products.

Issues explored should include audience comprehension and recall, the advertising’s aesthetic appeal, and the message’s credibility, relevance, and acceptance by the target group. Campaign planners should also keep in mind the “gatekeepers” who control outsiders’ access to the media. Because these station managers and editors have their own ideas about what is appropriate and effective, they should be involved in early planning and be asked to evaluate prelimi24 nary campaign materials. Media selection. Media should be selected according to the target Downloaded from content. ealthaffairs. org by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE 41 audience’s preferences and the objectives of the campaign. With its large and diverse audience, television is an excellent medium for bringing attention to an important issue; providing short, uncomplicated messages; evoking emotional responses; modeling new behavior and teaching health-related skills; and reinforcing the emergence of new social norms. A key obstacle to using this medium in a public health campaign is access.

But with the recent emergence of cable channels and syndicated programs, there are additional opportunities for targeting young people and 25 other specialized audiences. Radio shares many of television’s advantages but is far less costly. Moreover, with the diversity of stations on the air, it is relatively easy to reach narrowly defined audiences. For a national campaign, a major disadvantage of radio is the large number of independently owned stations that need to be approached. For adolescent audiences, syndicated programs with celebrity “disk jockeys” might provide a more feasible venue.

For either radio or television, the media plan should be based on audience rating systems or formative research that identifies the specific stations or programs that best reach the target audience at the lowest cost per contact. Even though adolescents, relative to other groups, are infrequent viewers of television, it remains the dominant medium for reaching them. Radio is a close second, taking on increasing importance as young people move into their mid-teens. Given its lower cost, radio should be given greater emphasis in substance abuse campaigns, especially when resources are limited.

Because existing print media have limited reach among adolescents, they should not be emphasized in most substance abuse prevention campaigns. Obtaining air time. Public service campaigns often fail to reach their intended audience. Indeed, public service messages are typically used by broadcast stations as “filler,” often aired at off hours with small audiences. One notable exception is the Media-Advertising Partnership for a Drug-Free America campaign, to which both television networks and local stations have donated large amounts of time.

Health advocates have responded to the competition for public service time by building relationships with local media gatekeepers who control access to their station or publication. Other recent campaigns have purchased air time either exclusively or in combination with public service time. This strategy is controversial; some health advocates fear that paying for media time will cause broadcasters to demand payment 26 for other public service advertising. Clearly, however, the restricted financial resources of nearly all public health agencies limit the extent to which this approach can be used.

Corporate sponsorship might provide a Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest 42 HEALTH AFFAIRS | Summer 1990 partial answer to this funding problem. For example, WBZ-TV in Boston increased the number of airings for a twenty-second spot on designated drivers by pairing it with a paid ten-second spot in which a corporate sponsor announced its endorsement of the idea. Another strategy for obtaining premium air time is to work directly with broadcasters to develop a full, high-visibility campaign.

In local communities, a broadcast station might want to develop an exclusive, station-sponsored campaign, one that focuses the station’s energy on a 27 single problem of public concern. A major network will sometimes undertake such a campaign as well. In such campaigns, newscasts, documentaries, talk shows, entertainment programs, public service spots, and editorials work in sync to inform and motivate the public. For some campaigns, the station or network will work in partnership with business, government, and voluntary organizations to create a direct ntervention, such as print materials, coupons for goods and services, and self-help kits. Corporate sponsors are often asked to provide funding in return for onair mention of their involvement. News coverage. Although public health groups frequently issue press releases, the releases often lack real news value or are timed improperly to compete with other stories. Further, public health groups seldom address their releases to individual reporters with whom they have established credibility over time.

Working relationships with print reporters are especially important, since local broadcast media often rely on area newspapers when deciding which stories to cover. To work effectively with the news media, public health advocates must 28 understand how news organizations define “news. ” Campaign planners must think creatively about how they can interest reporters in their message or story. In particular, when deciding what steps to take next in a program or campaign, planners should consider the public relations value of their various options.

One tactic is to conduct surveys or other research that can give new insight into a public health problem and its possible solutions. The newsworthy findings of this research can then be coupled with descriptions of current program efforts, announcements of upcoming events, and so forth. Public health advocates can also create “media events” that will generate news coverage, such as receptions, speeches or policy debates, awards ceremonies, or celebrity public appearances. Devising news events that will continue to capture reporters’ attention requires inventiveness.

Public health advocates too often assume that all of their important activities are automatically “news. ” Product or service promotion. Another way to attract media attention is to develop a new product or service that is promoted as part of a health Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE 29 43 promotion program. For example, commodities publicized through the mass media for the Pawtucket Heart Health Program include a cookbook and a “Four Heart” restaurant program through which eateries offer low30 fat, low-salt menu options.

Another approach is to establish links with commercially available products or services. By this strategy, called “cause-related” marketing, advertising for the products or services also carries a health message. Health advocates can emulate another strategy used by tobacco and beer companies: sponsorship of sporting events, concerts, and other cultural or youth-oriented activities. Because such events are often dependent on the fees paid by their sponsors, use of this strategy will be limited unless appropriate product or services companies cosponsor the event.

Another intriguing public relations vehicle, used by the Philip Morris tobacco company, is the publication of a “lifestyle” magazine (Philip Morris) distributed free to self-identified smokers. This periodical is designed to reinforce the reader’s self-definition as a smoker by publishing articles, features, and consumer advertising that associate this identity with an active, upscale lifestyle. A counterpart to Philip Morris is Zoot, a slick and highly popular “lifestyle” magazine distributed free to teens as part of an Alberta (Canada) campaign to promote healthy lifestyles that exclude substance use.

Campaign Evaluation Evaluation is necessary to monitor progress and demonstrate project impact. Most campaign evaluations have failed to capture the diversity and complexity of mass media effects, many of which set the stage for behavior change over the long term. Evaluations should be designed to measure these effects. For example, if the campaign’s objective is to move an issue to the top of the public agenda, the project’s success should be established by tracking the number of news stories on the issue, the 31 number of legislative proposals submitted and passed, and so forth.

Even with this broader purview in mind, campaign evaluators most often rely on random population surveys to measure campaign effects. While researchers often express doubts about the honesty of self-reports, respondents generally provide valid information if certain precautions are taken to maintain confidentiality. To evaluate local or regional campaigns, the best research design is a “quasi-experimental” design in which health-related outcomes in treatment communities exposed to the campaign are compared to those in 32 similar control communities. Unfortunately, fiscal limitations typically Downloaded from content. healthaffairs. rg by Health Affairs on October 18, 2011 by guest 44 HEALTH AFFAIRS | Summer 1990 restrict the number of communities assigned to each experimental condition to just one or two. A weakness of this research design is that the treatment and control communities might already differ in ways that either contribute to or mask differences in outcome. It should be noted, however, that matching the two sets of communities on relevant variables substantially improves the design. The random assignment of very large numbers of communities to experimental conditions would obviate this problem, but that is an unrealistic alternative in most cases.

Still, as many communities should be assigned per experimental condition as resources permit, because confidence in the research findings increases with the number of communities. Testing the impact of a national campaign is extremely difficult, because it is impossible to create meaningful comparisons with groups that have not been exposed to the campaign, The best alternative is to collect time-series data on attitudes, self-reported behavior, and other health indicators that are relevant to the campaign.

Time-series modeling requires that reliable and valid data be available for an extended period of time, both before and after the campaign, Sometimes, however, the only available data will be broad indicators, such as statistics on alcoholrelated traffic fatalities, rather than specific indicators of project objectives, such as data on the use of designated drivers. In these cases, a simple before/ after research design is a reasonable alternative.

With this design, confidence in the research findings is increased when (1) the campaign being tested is a signal event whose occurrence can be precisely defined in time; (2) the campaign’s objective is concrete, narrowly defined, and novel; and (3) the change shown after baseline is both sizable and rapid. The Future Role Of Mass Media Campaigns Mass media campaigns will continue to be a critical component of the nation’s long-term effort to encourage more responsible use of alcohol and prescription drugs by adults, to discourage tobacco and illegal drug use, and to promote universal abstinence among youth.

While mediabased health promotion campaigns are showing increased sophistication, the limits of what can be accomplished through mass communication are still being tested. Public health advocates are just now discovering a variety of public relations strategies that are used more widely in the commercial sector. The success of many health promotion programs, even those that are not primarily media-based, would be greatly enhanced if project leaders possessed the requisite knowledge and public relations skills for strategically employing the mass media. Downloaded from content. healthaffairs. rg by Health Affairs on October 18, 2011 by guest MEDIA AND SUBSTANCE ABUSE 45 Preparation of this paper was supported by grants to the Center for Health Communication, Harvard School of Public Health, from The Pew Charitable Trusts, The Commonwealth Fund, the Exxon Corporation, and the Helena Rubinstein Foundation. We thank Nathan Maccoby and Eric Brus for their thoughtful comments on an earlier draft of this paper. NOTES 1. L. Green and A. McAlister, “Macro-Intervention to Support Health Behavior: Some Theoretical Perspectives and Practical Reflections,” Health Education Quarterly 11, no. (1984): 322–339. 2. D. Roberts and N. Maccoby, “Effects of Mass Communication,” in Handbook of Social Psychology, vol. 2, Special Fields and Applications, ed. G. Lindzey and E. Aronson (New York: Random House, 1985), 547. 3. J. Farquhar et al. , “Community Education for Cardiovascular Health,” Lancet 1(4 June 1977): 1192–1195; and G. Egger et al. , “Results of a Large Scale Media Anti-Smoking Campaign in Australia: North Coast ‘Quit For Life’ Programme,” British Medical Journal 287 (15 October 1983): 1125–1128. 4. R.

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Basch, “Focus Group Interview: An Underutilized Research Technique for Improving Theory and Practice in Health Education,” Health Education Quarterly 14, no. 4 (1987): 411–448. 9. L. Johnston, P. O’Malley, and J. Bachman, Drug Use among American High School Students, College Students, and Other Young Adults: National Trends through 1985 (Rockville, Md. : National Institute on Drug Abuse, 1986). 10. K. Yamaguchi and D. Kandel, “Patterns of Drug Use from Adolescence to Young Adulthood: III. Predictors of Progression,” American Journal of Public Health 74, no. (1984): 673–681. 11. D. Kandel and J. Logan, “Patterns of Drug Use from Adolescence to Young Adulthood: I. Periods of Risk for Initiation, Continued Use, and Discontinuation,” American Journal of Public Health 74, no. 7 (1984): 660–666. 12. Roberts and Maccoby, “Effects of Mass Communication. ” 13. Lefebvre and Flora, “Social Marketing and Public Health Intervention. ” 14. P. Bandy and I? President, Review of the Literature in Drug Abuse Prevention and Mass Media (Rockville, Md. : National Institute on Drug Abuse, 1982); and R.

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Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest 46 HEALTH AFFAIRS | Summer 1990 18. Ibid. 19. L. Graham and L. Hamdan, Youthtrends: Capturing the $200 Billion Youth Market (New York: St. Martin’s Press, 1987). 20. Ibid. 21. S. Chapman and G. Egger, “Forging an Identity for the Non-Smoker: The Use of Myth in Health Promotion,” International Journal of Health Education 23, no. 3 (Supplement 1980): 1–16. 22. Ibid. 23. McGuire, “Attitudes and Attitude Change. ” 24. Flay, “Mass Media Linkages with School-based Programs for Drug Abuse Prevention. 25. Graham and Hamdan, Youthtrends. 26. P. Bloom and W. Novelli, “Problems and Challenges in Social Marketing,” Journal of Marketing 45, no. 1(1981): 79–88. 27. J. Wishnow, The Activist: A Broadcasters’ Step-By-Step Guide to Total Station Public Affairs Projects (Washington, D. C. : National Broadcast Association for Community Affairs, 1983). 28. J. Winsten, “Science and the Media: The Boundaries of Truth,” Health Affairs (Spring 1985): 5–23. 29. Lefebvre and Flora, “Social Marketing and Public Health Intervention. ” 30. T. Lasater, R. Lefebvre, and R.

Carleton, “The Pawtucket Heart Health Program: IV. Community Level Programming for Heart Health,” Rhode Island Medical Journal 71, no. 1(1988): 31–34. 31. L. Wallack, “Assessing Effects of Mass Media Campaigns: An Alternative Perspective,” Alcohol Health and Research World 5, no. 1(1980): 17–29. 32. B. Flay and T. Cook, “Three Models for Summative Evaluation of Prevention Campaigns with a Mass Media Component,” in Public Communication Campaigns, ed. R. Rice and C. Atkin (Beverly Hills, Calif. : Sage, 1989). Downloaded from content. healthaffairs. org by Health Affairs on October 18, 2011 by guest