Challenging Dogma

...Using social sciences to improve the practice of public health

Sunday, April 22, 2007

Prosecution, Pressure, and Promotion: How Innovative Social Science Models Can Fix Failing Approaches to Combating Underage Drinking - Anish Sen

Alcohol is the most widely abused drug among adolescents in the United States. It is merely repetitive to continue to provide statistics and information concerning the breadth of the current underage alcohol problem plaguing the United States—a myriad of scientific investigations and statistical research projects have been conducted and results published regarding this pressing issue. Simultaneously, almost a similar number of interventions have been designed across communities in the United States to combat this public health problem. But why is underage drinking still such an inherent problem in American society despite the millions of dollars and man-hours spent on interventions to reduce it? This article argues that the major reasons that current public health interventions are failing are their dependence on health belief model-based solutions like crackdown and prosecution, their failure to utilize Social Learning Theory principles in their approaches, and their failure to incorporate advertising theory to counter the effects of alcohol-company advertisements.

The Failure of the Health-Belief Model
The health-belief model was initially developed in the 1950s as a psychological model to help scientists and policy-makers understand health-related behaviors and has since grown to become one of the most widely-employed (if not the most widely-employed) model for contemporary public-health interventions (1). The model claims that if an individual perceives a susceptibility to the outcome, perceives the severity of the outcome, weighs the barriers and benefits, and develops and intention to take action, a specific behavior will inherently follow. Hence, based on this seemingly logical and rational decision-making process, many interventions have been developed to influence this process in adolescents considering drinking.

For example, one common intervention has involved increasing the costs of alcohol (e.g. via taxation) to introduce a larger barrier to underage drinking (2). The premise behind such interventions is that when weighing the benefits and barriers to drinking—as predicted in the health-belief model—if the cost of obtaining the alcohol is too high, minors will intend not to drink, and thus not do so (3). Yet upon evaluation of such interventions, it is found that although statistically significant decreases in consumption do occur, the overall burden of underage drinking remains strong, and that such approaches have achieved little in curbing adolescent’s drinking behaviors. A major factor left unconsidered by the model is the contribution of social-level peer pressure—discussed further in the next section.

Moreover, common interventions have focused on increasing enforcement of underage drinking laws and developing more serious consequences for breaking such laws (2). For instance, the Leadership Organization to Keep Children Alcohol Free has suggested four major prevention strategies to law enforcement: “break up parties, enforce keg registration, enforce establishment policies, [and] conduct compliance checks” (4). The health-belief-model-based premise in this intervention is that increasing adolescents’ perceptions of the severity of underage drinking (i.e. the major legal troubles they would be in by drinking) would effectively reduce their intent to drink, and hence alter their behavior. Yet, as in the case of alcohol taxation, underage drinking continues to be a problem despite these major legal approaches (8).

One such explanation for this failure arises from the health-belief model’s failure to consider the social idea that risks are enticing to adolescents. Many social scientists have documented evidence that risky behavior is attractive to teenagers, and specifically with regard to the risks associated with alcohol consumption. For instance, Dr. Franzkowiax of the Health Research Centre of Heidelberg Germany says, “The majority of adolescents react to preventive measures and statements about health with either refractoriness or non-compliance, blaming adults for alleged "hypocrisy" and double-standards over health matters. An important–but hitherto scarcely discussed–part of the background to this problem would seem to lie in the "blindness" of health researchers and educators to the multiple developmental functions of the health risk-taking process for the adolescents themselves” (5). Clearly, the psychological theories incorporated in the health-belief model have failed to consider this important factor in children’s decisions to engage in underage drinking, and hence, interventions reliant upon the health belief model (like the aforementioned increased enforcement intervention) are destined to overlook this major contributor.

In addition, the model is severely constrained by its assumption that health-related decisions are carried out rationally and thoughtfully. Not only does the above-mentioned attraction to risky behavior prove irrationality in adolescent decision-making, but other factors like an adolescent’s perceptions of risks over time are also overlooked by the model. Studies have shown that adolescents frequently do not rationally understand the extent and implications of risk. For example, one study found that “The lack of experience with and not worrying about serious health consequences may desensitize children to potential health risks” (6). Hence, since children are unlikely to realize the severity of their actions, they cannot be expected to rationally evaluate their behaviors prior to drinking, and thus, health-belief-model-based interventions designed to introduce barriers to drinking (such as alcohol taxation), increase the perception of the severity of drinking (such as tougher prosecution and legal enforcement), or increase the perceived susceptibility of drinking, are destined to failure.

The Importance of Social Learning Theory
Another major criticism of current underage drinking prevention interventions has been their failure to incorporate Social Learning Theory principles in their approaches. Social Learning Theory was developed in the 1970s by A. Bandura, who claimed that “…most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action” (7). Essentially, the theory argues that people’s behaviors are determined by replicating what other are doing around them. The theory also rests on three major principles:
1. The highest level of observational learning is achieved by first organizing and rehearsing the modeled behavior symbolically and then enacting it overtly.
2. Individuals are more likely to adopt a modeled behavior if it results in outcomes they value.
3. Individuals are more likely to adopt a modeled behavior if the model is similar to the observer and has admired status and the behavior has functional value. (7)
With regard to the underage drinking issue at hand, this theory has been found to be particularly pertinent to adolescents, who are more likely to model behaviors of others, including peers, celebrities, and adults. The theory initially posits that adolescent’s underage drinking actions are initially dependent on their observing others drinking (such as parents or other adults, celebrities, and other friends). Moreover, it argues that minors are more likely to drink since the outcome is valuable to them (such as popularity, acceptance among other peers, a level of relation with popular celebrities, and a perception of maturity on par with their parents or other adults). Finally, it presents the principle that adolescents are more likely to engage in underage drinking if their model is admired (such as a celebrity, or a popular friend) and if the behavior (i.e. drinking) could functionally help the minor achieve his or her value (i.e. popularity, acceptance, etc.)

However, when current interventions are analyzed to see if they account for these important social science principles, very few interventions are found to incorporate these ideas. For instance, efforts to enact and enforce zero-tolerance laws and increase the minimum drinking age throughout the United States have, and will continue to, prove ineffective. Regardless of how many laws are passed and enforced and regardless of the extent of the scare-tactics employed, the social learning theory suggests that adolescents will continue to engage in underage drinking until models are adjusted and values are changed. Under most current interventions, models will remain the same (i.e. popular, risk-taking friends and celebrities), and hence children will continue to emulate the same behavior that they have in the past. Similarly, society’s high value upon partying, engaging in high-risk behaviors, and living a “fun life” regardless of the consequences will continue to attract children to participate in underage drinking. As the model predicts, only when children stop observing and rehearsing underage drinking, stop valuing these aforementioned ideals, and stop modeling certain admired individuals will underage drinking possibly be reduced.

Furthermore, the Institute of Medicine found that “…there is a strong possibility that youthful exposure to alcohol content in entertainment media contributes to early initiation of alcohol use” (9). Since the entertainment media are highly valued by many American adolescents as role models, and the celebrities of such media frequently engage in drinking behaviors, it is very obvious based on social learning theory that minors may model such behavior and, as a result, engage in underage drinking. Yet an examination of popular interventions with respect to their addressing this issue reveals that virtually no action has been taken to reduce such an influence on children’s behavior. Almost no public health interventions to curb underage drinking have even mentioned the importance of addressing entertainment-based drinking values, let alone take any action to curb such an influence. Hence, a fundamental failure of current interventions to address modeling as a major behavior-determining factor has contributed to the failure of status quo programs.

The Importance of Advertising Theory
Basic advertising theory has found that three major advertising-related dimensions affect people’s behaviors: an appeal to one’s benefits and core values, a promise made in the advertisement, and a support for that promise provided in the advertisement (10). Unfortunately, these three principles have been commercially exploited by alcohol companies to entice consumers (including adolescents), while the public health arena has failed to consider the power and effectiveness of this social science theory. Alcohol companies frequently appeal to adolescents’ values of social acceptance by promising popularity and favorable reception to those who heed the advice of the advertisement—drinking that company’s alcohol product.

Much data has been generated demonstrating the link between alcohol advertising and drinking, but few interventions have focused on this important connection. For instance, the Institute of Medicine found that 53 percent of television programs popular among teenagers portrayed alcohol use, and more episodes correlated drinking with a positive experience than a negative one (12). Moreover, research published in the Journal of Adolescent Health Care found that “…alcohol commercials contribute to a modest increase in overall consumption by teenagers” (13). Numerous other studies have found a similar correlation.

An in-depth analysis of the relationship between television-based alcohol advertising and drinking knowledge and beliefs among adolescents revealed that alcohol companies have not only used the previously mentioned social advertising theories, but also established their own advertising model by which they appeal to consumers, and inadvertently, adolescents (11). The quite complex model developed by alcohol companies incorporates distinct influences on adolescent’s drinking knowledge and beliefs, and culminates upon an adolescent’s intention. The new model states that peer approval, sex, television watching, and parent’s drinking all affect three principles—knowledge of brands, knowledge of slogans, and advertising awareness. These factors, in turn, affect an adolescent’s negative and positive beliefs, which influence his or her drinking intention. Although it fails to link this intention to a final behavior, this model, as described by Grube and Wallack, provides a very useful insight into the method of persuasion employed by alcohol companies (specifically beer companies), and thus creates the possibility for interventions to intercede on each step in the model.

Using this aforementioned model employed by alcohol companies to test the appropriateness of current interventions to reduce adolescent drinking yields expected results—most interventions fail to curb this appeal generated by advertising. While alcohol companies have mastered advertising theory to promote adolescent drinking (possibly inadvertently), public health interventionists have not. Interventions—including ones such as taxation, enforcement, prosecution, zero-tolerance measures, and efforts to raise minimum drinking ages—have not been designed to affect individual stages and steps in either traditional advertising theory, or alcohol companies’ new advertising model. Successful interventions would not only work to curb such steps/factors (like downplaying peer approval and encouraging parents to not drink in front of minors), but also work to reverse such advertising possibly with competitive advertising employing similar principles.

This competitive social advertising could take advantage of both the theories used by alcohol companies in their model (as mentioned above), as well as the traditional aspects of social advertising theory—such as appealing to a core value, making a promise, and supporting that promise with an outcome. Novel interventions should focus first on recognizing the core values of adolescents (such as popularity or acceptance among peers) and subsequently making promises to adolescents to achieve those values via methods not involving alcohol.

Additional methods may involve restricting alcohol company advertisements. For example, a model program termed “Communities Mobilizing for Change on Alcohol” (CMCA) encourages media education to counter such advertising. The organization suggests that “Advertising outlets can be influenced to remove alcohol advertising from public places or wherever youth are exposed to these messages…[and that]… [c]ommunities can restrict alcohol companies’ sponsorship of community events” (14). These actions would effectively cut off a major integrating center in the advertising theory employed by alcohol companies—advertising awareness. Unfortunately, the CMCA is one of just a handful of such “informed” interventions utilizing social advertising theory to combat underage drinking, while the majority of interventions continue to follow traditional health-belief-model-based solutions.

Underage drinking is, and continues to be, a major problem for American society. Regrettably, public health interventionists have employed ineffective and unrealistic models to develop their interventions to curb this issue, and have failed to consider new and more efficacious social models (such as social learning theory and advertising theory). Though the rational decision-making health-belief model appears logical and applicable in theory, and has been used for decades in public health, in real application, it has failed to develop effective solutions. Interventions founded on this model, including taxation, prosecution, and strict enforcement (among others), have not proven to substantially decrease underage drinking. Newer approaches, informed by social science principles and theories, must be employed by public health practitioners if the underage drinking crisis in the United States is to be reduced.

1. Health Communication. Health Belief Model: Explaining Health Behaviors. Enschede, Netherlands: University of Twente.
2. National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert: Underage Drinking. Bethesda, MD: U.S. Department of Health & Human Services.
3. Chaloupka F.J.; Grossman M.; and Saffer H. The effects of price on the consequences of alcohol use and abuse. Recent Developments in Alcoholism. New York, NY: Plenum Press, 1998.
4. Leadership to Keep Children Alcohol Free. Law Enforcement. Washington, DC: Leadership to Keep Children Alcohol Free.
5. Franzkowiax P. Risk Taking and Adolescent Development: The functions of smoking and alcohol consumption in adolescence and its consequences for prevention. Health Promotion International 1987; 2:51-62.
6. Greening L. et. al. Predictors of Children’s and Adolescent’s Risk Perception. Journal of Pediatric Psychology 2005; 30:425-435.
7. Theory into Practice. Social Learning Theory A. Bandura. Vancouver, BC: Theory into Practice.
8. Wechsler H. et. al. Underage College Students’ Drinking Behavior, Access to Alcohol, and the Influence of Deterrence Policies. Journal of American College of Health 2002; 50:223-236.
9. Bonnie R. and O’Connell M. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: The National Academies Press, 2004, p. 146.
10. Illuminations. Toward a Critical Theory of Advertising. Austin, TX: The University of Texas at Austin.
11. Grube J.W. and Wallack L. Television Beer Advertising and Drinking Knowledge, Beliefs, and Intentions among Schoolchildren. American Journal of Public Health 1994, 84:254-259.
12. Bonnie R. and O’Connell M. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: The National Academies Press, 2004, p. 153.
13. Atkin C.K. Effects of televised alcohol messages on teenage drinking patterns. Journal of Adolescent Health Care 1990; 11:10-24.
14. Substance Abuse and Mental Health Services Administration. SAMHSA Model Programs: Communities Mobilizing for Change of Alcohol. Gainesville, FL: U.S. Department of Health & Human Services.

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