Why Calling a Fat Kid a Fat Kid Doesn’t Solve Childhood Obesity -Jessica Ochalek

Today over one third of U.S. adults and 17% of U.S. children are obese. In the last three decades, obesity rates for adults have doubled and rates for children have tripled. However, the burden of obesity is not evenly distributed, and falls heavily on minorities. The 2009 Behavioral Risk Factor Surveillance System report showed that “blacks were 51% more likely and Hispanics were 21% more likely than non-Hispanic whites to be obese” (1). It is also geographically unevenly distributed with the American Midwest suffering higher obesity prevalence rates than the rest of the country. Cincinnati, Ohio is a beautiful Midwestern city situated at the southern edge of Ohio, across the Ohio River from Kentucky. However, like many Midwestern cities and states, Cincinnati has seen an alarming increase in obesity among adults and children in the last few decades. According to CDC 29.6% of Ohioans were obese in 2009. This increase has serious health consequences for adults and children. Obesity related diseases like type 2 diabetes, which previously only affected adults, is now affecting children (1). Obese children are also at higher risk of suffering cardiovascular disease. Obesity, including childhood obesity, is known to be a risk factor for a number of diseases including cancers, stroke, respiratory problems and reproductive health problems. The annual hospital costs related to childhood obesity increased from $35 million in the period from 1979-1981 to $127 million in the period from 1997-1999 (1).

In 2008 the nonprofit Center for Closing the Health Gap (2) in Greater Cincinnati began a campaign aimed at preventing childhood obesity. Childhood obesity prevention is a goal that fits perfectly within CCHG’s mission, which includes increasing awareness about health disparities (2). The childhood obesity epidemic in the Greater Cincinnati area disproportionately affects minority children. CCHG’s website reports that the rate of overweight and obesity in Hamilton County is 43% among Black, Non-Hispanic children and 21% among White, Non-Hispanic children. The negative consequences to health that may result from obesity are grave. The city was seeing children with hypertension and worrying rates of type II diabetes. Secondly CCHG saw that obesity disproportionately affected children of low-income parents and minority children, particularly Black, Hispanic and Appalachian children. To work toward preventing childhood obesity the organization initiated a campaign called “Do Right!” The specific target of the childhood prevention portion of the program aimed at “improving the health and well-being of children at Rockdale Elementary that are overweight and obese” (2). Rockdale Elementary is part of the Cincinnati Public Schools system and enrolls about 500 preschool and elementary school students from grades PK-8.

The “Do Right!” children’s program is multi-faceted. Its in school components include screening for BMI to identify overweight and obese children, referral for obese children to an after school physical activity and nutrition program. The program includes nutrition every other week by a dietician, physical activity and bi-weekly parent education and information sessions to discuss nutrition. The program also included 1-minute health tips on the radio, parent workshops in development and City School Awareness Presentations (2). Finally, the program ran a concurrent obesity awareness campaign that included billboards, bus shelters, radio advertisements, ads in minority newspapers and the website: www.dorightcincy.org. They feature obese children mowing down on big, greasy burgers in front of plates of onion rings with the words “Are we feeding our kids to death?” in large print. Below, they provide the Do Right! campaign’s website and phone number with the words “for information on how to combat obesity.” These ads are the focus of this critique.

Defeating Self-Efficacy

First and foremost it alienates the very population it aims to help. Dwight Tillery, the executive director of CCHG, purports that the campaign was designed to serve as a wake-up call for families. It aims to incentivize parents to take the health of their children more seriously by showing them just how serious obesity is. Tillery said, “We can’t afford to be politically correct on this issue” (3). Political correctness or lack thereof aside the means simply do not justify the end. Whether or not parents are shocked into understanding the gravity of childhood obesity, children who see these ads are sure to feel alienated. The ads effectuate a pervasive sense of hopelessness, powerlessness and defeat. They say, “you’re obese and you’re being fed to death.” There is nothing in this message that engenders a sense of self-efficacy, or the idea that a lower, healthier weight is an attainable goal. This deficiency is the ad’s primary shortcoming. Self-efficacy as defined by psychologist and father of Social Cognitive Theory, Albert Bandura, is one's belief in one's ability to succeed in specific situations. The concept of self-efficacy is central to Social Cognitive Theory (4). Social Cognitive Theory asserts that behavior is based on the interaction between one’s environment, the behaviors one witnesses, and the individual themselves. Ads like these posted by CCHG construct a negative outcome expectation and in so doing dismantle whatever self-efficacy they could otherwise have fostered. It simply isn’t enough to provide a website and helpline when the ad itself effectively destroys self-efficacy.

Labeling and Normalizing Obesity

Not only do these ads beget powerlessness as shown in the last paragraph, but they concurrently label and normalize childhood obesity. The relationship between labeling and normalizing obesity presents a double-edged sword for potential public health interventions aimed at preventing childhood obesity. The normalizing of obesity comes with a hefty price tag including rising economic costs. According to the Brookings Institution, “the total costs of obesity in the U.S. alone may exceed $215 billion annually” (5). The direct medical costs resulting from obesity in the U.S. have been estimated to account for over 9% of the national medical bill (6). Societal costs are also extensive. Obese children are less likely to be sent to college by their parents (6). Obese adults are less likely to be given jobs, and miss more work, overall costing employers something on the order of $4 billion. Obese children are at much higher risk of becoming obese adults than their thinner peers (7 - 8). In sum, normalizing obesity, particularly in children, presents a great hazard to personal health and has a major negative impact on costs at the society level.

On the flip side of normalizing, labeling obese children forces them to contend with the heavy stigma associated with obesity, decreasing the likelihood that they will overcome the many hurdles to health and wellness placed on them by society. Obesity is the fourth most common type of discrimination people report experiencing in the U.S. (9). Simply labeling children as obese has the potential to greatly influence their behavior. While the ads don’t literally use the word “obese”, they make it visually quite clear that they’re targeting obese children, and point a finger at poor eating habits. Labeling Theory (which is also known as Social Reactance Theory) posits that labeling an individual influences their behavior and more often than not causes them to conform to the stereotypes of the label in a self-fulfilling prophecy (10 - 11). Obese children must endure negative stigma not only from their peers, but also by their teachers and themselves (9). They are often ascribed negative characteristics including mean, stupid, loud, sloppy, ugly, lazy, sad, and lacking in friends (12 - 14). Obese children can become trapped within this self-fulfilling prophecy and may thus accept these traits as part of their role in society as an “obese child”. Studies have shown that the stigma associated with obesity causes an increase in coping methods like binge eating instead of being a contributing factor to motivation to lose weight and stay healthy (9, 15).

Not only are the children taught how to act by the characteristics attached to their label, but they learn through cognition in conjunction with observing behaviors within their environment. These elements operate reciprocally. For example, the environment in which one is raised affects one’s cognition and perceptions of behaviors that one witnesses. In state where approximately 30% of people are obese and where television stations air shows like “More to Love” or “Ruby” (in which the star, Ruby, spends three seasons trying lose weight only to end the third season having gained over 50 pounds) obesity is not likely to be perceived as abnormal (1). It is likely seen simply as the status quo. Posting health billboards featuring obese children eating is wading into dangerous territory. It risks adding more obesity normalizing media to the local environment and simultaneously reinforces the stereotypes and stigma associated with obesity, particularly qualities like lack of self-control.

SCAREMONGERING

Proponents of the campaign cite the fact that 93% of parents of obese children didn’t perceive their kids as being an abnormal weight (16). Research backs up this frightening assertion and shows that parents of overweight children consistently underestimated their children's weight (17 - 18). CCHG’s Childhood Obesity Awareness Campaign aims to inform parents that their children are at risk for serious health outcomes and the organization has deemed that shocking parents is necessary to do so. This scaremongering tactic assumes that by informing parents that their children are at risk of very serious health outcomes like death, they will be moved to act. This assumption takes for granted that people are rational decision makers. Rational decision-making generally entails defining the problem, identifying criteria relevant to the problem, considering all possible solutions, calculating the potential consequences of each solution, and choosing the best option. Many public health interventions are based on this same assumption. It is in fact the very basis of the Health Belief Model, which is commonly used in public health interventions. This model postulates that a behavioral change at the individual level depends on a person’s attitudes toward expected outcomes, the strength of those attitudes and the resulting outcome expectancies, as well as the individual’s perceptions of how others see them, and what the societal norms are (4). All of these factors meld to produce intention, which is followed by behavior. When applied to a parent’s role in preventing childhood obesity, as CCHG has done, the model suggests that if parents become aware of the potential hazardous heath outcomes of obesity and their attitudes toward obesity change, they will intend to prevent or reverse obesity in their children and that intention will lead to a change in behavior. This progression assumes rationalism prevails. Unfortunately assuming rationality fails to account for an individual’s subconscious thought process, irrational decision-making, group behavior and societal and environmental factors, all of which are crucial variables guiding behavior (4, 19, 20).
Irrational decision-making often relies upon the way that a particular issue is introduced or framed. Framing is a method of presenting a fact, topic or idea in a specific light so as to change how it is received among the audience to whom it is being presented. The concept of framing is central to Prospect Theory. Put simply, Prospect Theory states that people value gains and losses differently and that individuals make decisions based on perceived gains rather than perceived losses (21). Given two options with equal outcomes, an individual would choose the outcome expressed in terms of possible gains instead of the one expressed in possible losses. CCHG’s billboard frames childhood obesity in terms of the expected health outcome as a loss. Presenting the issue of childhood obesity by framing it within the context of not only a negative outcome but its most terrifying potential outcome, premature death from obesity related health problems, sets the campaign up for failure.

DO RIGHT! SUCCESSES: A SPRINGBOARD

While CCHGs program’s billboard and ad campaign are majorly flawed, there are a number of things the Do Right! campaign as a whole has gotten right. The organization was correct to take multi-faceted and all-encompassing approach to targeting childhood obesity prevention. Research suggests that families, schools and communities should all be included in programs aimed at preventing and reducing childhood obesity (22). Targeting parents exclusively has also been shown to be effective in reducing the BMI of overweight and obese children. A recent study from the United Kingdom showed that the BMI percentile of children whose parents were provided with eight sessions of cognitive-behavioral therapy for weight loss decreased significantly by 2.4% in the treatment group (23). Community involvement or not, targeting parents is crucial childhood obesity prevention programs. Children of obese parents are more likely to be obese themselves. Children aged 15 to 17 years old with at least one obese parent are over twice as likely as children with no obese parents to be obese adults. Children aged 1 to 2 years old were three times as likely to be obese as their peers who didn’t have an obese parent (24). Beyond the nuclear family, recent research has shown that obesity also spreads through social networks. A study conducted using data from Framingham, MA found that the chances of someone becoming obese increase 57% if they had a long-term friend who was obese (25). However, succeeding in utilizing parent and community involvement in childhood obesity prevention programs is challenging. As anyone who has ever tried to lose even a few pounds knows, attempting to lose weight can be daunting. For an obese person the barriers to weight loss, potentially including difficulty engaging in physical activity, addiction and lack of social support, can often seem indomitable. At any rate, with at minimum an adequate level of support within the environment and from family and community members, childhood obesity can be overcome. Methods to resolve each of the previously outlined failings within the billboard and ad campaign are presented in the following three sections.

POSITIVITY-MONGERING

As addressed in a previous section of this paper, the Health Belief Model as a champion of rational decision-making, and as it was implemented, was not an effective archetype from which to create the childhood obesity prevention billboard and ad campaign. On the other hand, framing, as delineated within Prospect Theory, can be an incredibly useful tool with which to begin to reconstruct this intervention. Bearing in mind that the original intent of the ad was to create awareness of childhood obesity as a serious problem among parents of obese children, the following proposed ad is aimed at both parents and children who will inevitably see the ads as well. This approach utilizes an entirely novel angle that frames health, with regard to weight, as a desirable and attainable outcome.

The proposed billboards will feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This sends the following messages; physical activity is fun; obese children are also entitled to fun; obese children can do sports. In this way fighting childhood obesity through physical activity is framed in a positive light, as a fun and attainable goal. Making weight-loss and health attainable completely reverses the billboards, taking them from negative to positive and fomenting self-efficacy in children.

ENGENDERING SELF-EFFICACY BY NORMALIZING HEALTH

Labeling and normalizing obesity both have serious negative consequences at the individual and thus also societal level. They contribute to lower levels of self-esteem among obese children, and contribute to extensive monetary costs at the national level. A good public health campaign will succeed in achieving improved health and preventing obesity without further contributing to the extensive and damaging effects of labeling. While the billboard proposed in the prior section may be argued as normalizing obesity, it should be seen as normalizing activity among children of all shapes and sizes. Obese children are usually stereotyped as stupid, sloppy, ugly and lazy. In personal stories shared on blogs obese adults recount experiences that, in line with research published in peer reviewed journals, illustrate the cyclical nature of the self-fulfilling prophecy. In a blog published on Newsweek, Leslie Kinzel wrote,

“Prior to being told I was fat by my well-intentioned pediatrician … I'd spent my life as an active and athletic child, my fatness no obstacle in keeping up with my peers (and frequently besting them). As I got older I came to understand what being fat meant: fat kids were lousy at sports, and those who tried to play were to be mocked for it. Fat kids were always picked last, and though I was never picked last, I came to fear that it would inevitably happen. So I stopped playing. I backed away from sports and games altogether.” (26)

Her account is unfortunately not uncommon and characterizes the major negative impacts that labeling has on obese children. Obesity carries such stigma that for many children it becomes the single characteristic by which they feel most defined. At the end of her post Kinzel pleads,
“Call it a campaign against childhood couch-sitting. Call it a drive to get kids to go outside and play. Call it a movement to educate children on basic nutrition and how their amazing growing bodies work for them. But don't single out the fat kids. If I am any indication, doing this will only ensure that this generation will be fatter than ever, dragging behind them some heavy baggage around food issues and low self-esteem.” (26)

Kinzel’s well-put conclusion holds true given what has been learned from the failures of the Health Belief Model and the potential outcomes associated with Label Theory and Social Reactance Theory. It is absolutely necessary to change the personal characteristics associated with the obesity label. Getting obese children re-involved in sports and other physical activities will help to get rid of the stereotype that obese children can’t play sports. This will serve a dual purpose. It will encourage other obese children to take up arms so to speak and join the revolt against stereotypes. At the same time becoming involved in sports once again or perhaps for the first time will have positive health effects. While these effects certainly can’t be expected to be immediate they will have a positive effect on the local environment that should grow exponentially.

ENGENDERING SELF-EFFICACY BY REVOLTING AGAINST THE LABEL

Inciting obese children in Cincinnati to rise up against the fat label takes advantage of the mechanisms described in Psychological Reactance Theory. This theory asserts that perceived limitations to freedom or autonomy provoke an aversive affective reaction in people (27). In other words, if an individual perceives that their freedom has somehow been limited they will become provoked to regain it. A wonderful example of psychological reactance at work is the Truth campaign, which aims to curb youth use of tobacco by inciting a rebellion of sorts among young people. The campaign’s theme is “truth, a generation united against tobacco” (28). The Truth campaign successfully framed the tobacco industry as a liar that was hiding the truth from teens. In doing so they provoked teens to rebel against big tobacco and its lies, successfully decreasing youth smoking initiation rates.

The proposed alternative billboards showing obese children standing up to the labels and stereotypes associated with childhood obesity will do the same. This reaction is particularly common when individuals feel obliged to adopt a particular opinion or engage in a specific behavior (27). The billboards will bring to light these expectations and the violation of freedom that they cause for obese children, inspiring rebellion. In inciting this silent, healthy insurrection the campaign will be rekindling self-efficacy in obese children, which has a powerful effect on an individual’s level of motivation. “Boredom and apathy occur when a challenge is too small; anxiety and withdrawal occur when a challenge is too great; curiosity and engagement occur when the challenge is optimal” (29). If children don’t feel like they will succeed in losing weight or getting healthy they are much less likely to try to do so. Engendering self-efficacy through these billboards is an indispensible component of a successful childhood obesity prevention public health campaign. Recent work has found that “exercise’s association with weight loss was better explained through psychological, rather than physiological (ie, caloric expenditure), pathways” proving even further the importance of self-efficacy in weight loss (30). Giving obese children a common cause and an enemy to take down will help to create this self-efficacy, aiding in reducing and preventing childhood obesity over time.

CONCLUSION

Childhood obesity is a serious public health threat that requires sincere and practical interventions. The potential health consequences that are associated with childhood obesity are grave. They are harmful both to the individual and at the national level. Obese children are at increased risk for type II diabetes, cardiovascular disease, respiratory problems and future reproductive problems. They have added to increased medical costs at the national level, and as childhood obesity prevalence rates are higher among lower income quintiles the increased prevalence of childhood obesity has contributed to growing government expenditures on health (1). Practical, effective solutions are crucial in the fight to prevent and decrease childhood obesity.

In order to create a billboard campaign that effectively reduces and prevents childhood obesity while carefully avoiding potential adverse affects that such a billboard could so easily have, as evidenced by the one used by CCHG, social and behavioral sciences theories should be employed. Social Cognitive Theory, Labeling Theory (which is also known as Social Reactance Theory), the Health Belief Model, Framing Theory (as well as Prospect Theory) and Psychological Reactance Theory were used to analyze and critique CCHG’s billboard and ad intervention. CCHG’s billboard intervention was found to be inappropriate on the grounds that it contributed to defeating self-efficacy among obese children, added to labeling and normalizing childhood obesity and resorted to terrorizing parents in an effort to create awareness and incite a behavior change among parents and children. These same theories were then employed to suggest an appropriate intervention to replace CCHG’s billboard ads. The proposed replacement intervention consists of billboards that feature obese children playing sports and having fun with their thinner peers. The phrase “Are we feeding our kids to death?” will be replaced with the phrase “Are you having as much fun as you deserve to be?” This intervention is based on engendering self-efficacy by reframing the childhood obesity issue in a positive light, normalizing healthy choices among obese children and using Psychological Reactance Theory to empower children to fight against the labels associated with childhood obesity. Casting a glow of optimism on the problem will help to bring back to life self-efficacy that has been squashed by labeling and stigma. Social and behavioral sciences theories were instrumental tools in understanding the effects that the Cincinnati CHG’s billboards could be expected to have on the target population, as well as any projected externalities, and in creating a better alternative.

REFERENCES
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Critique of the Eat Smart Play Hard Campaign to Prevent Childhood Obesity-Gauri Apte

Overweight and obesity are significant public health problems in the United States (US). [1] The number of overweight adolescents has tripled in the last years and prevalence among younger children has more than doubled (See figure 1). [2,3,4] Not only has the proportion of overweight individuals increased but the heaviest children in a recent National Health and Nutrition Examination (NHANES) survey were markedly heavier than those in previous surveys. [2,3]
Being overweight during childhood and adolescence increases the risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression and type 2 diabetes as a youth.[5] It also has a large number of long-term adverse health outcomes. Overweight adolescents have a 70 percent chance of becoming overweight or obese adults, which increases to 80 percent if one or more parent is overweight or obese. [6] Obesity in adulthood increases the risk of diabetes, high blood pressure, high cholesterol, asthma, arthritis, and a general poor health status [7].
Understanding the causes of childhood obesity can provide the opportunity to focus resources, interventions and research in directions that would be most beneficial in addressing the problem. The causes of childhood obesity are multi-factorial. Excess weight in children and adolescents is generally caused by a lack of physical activity, unhealthy eating patterns resulting in excess energy intake, or a combination of the two. Genetics and social factors, such as socio-economic status, race/ethnicity, media and marketing, and the physical environment – also influence energy consumption and expenditure. Most factors leading to being overweight and obese do not work in isolation and solely targeting one factor may not going to make a significant impact on the growing problem. [8] Specific causes for the increase in prevalence of childhood obesity are not clear and establishing causality is difficult since it involves research which must employ long study times to see if there is an interaction of factors leading to an increase in the prevalence or the prevention of obesity during childhood and adolescence. Under-reporting total food intake, misreporting of what was eaten, and over reporting physical activity are all likely potential biases that may affect the outcomes of studies in this area.[9]
This paper briefly describes the current intervention for prevention of childhood obesity and proposes a new modified intervention. It presents three critiques of this current intervention and then defends the new intervention as a tool to overcome these critiques. In the end it gives a conclusion derived from this exercise.

Current Interventions: The Eat Smart, Play Hard Campaign (ESPH)
This campaign is a part of the U.S Department of Health and Human Service's 'Childhood Obesity Prevention' program [10] and is funded by the U.S Department of Agriculture (USDA). This campaign is a national nutrition education and promotion campaign designed by USDA's Food and Nutrition Service (FNS) to convey science-based, behavior-focused and motivational messages about healthy eating and physical activity. [11]
Messages developed for the campaign are based on the most recent edition of the Dietary Guidelines for Americans [12] and the Food Guide Pyramid. [13]
The initial campaign messages focus on four basic themes: breakfast, snacks, balance and physical activity. The program is designed to: 1) Encourage families to adopt behaviors that are consistent with the Dietary Guidelines for Americans and the Food Guide Pyramid; 2) Communicate behavioral and motivational nutrition education and physical activity messages to children and caregivers; and 3) Foster positive behavior change to promote nutrition and health, and reduce the risk for obesity and chronic diseases.
The target audience for this campaign is the diverse population of children (ages 2 to 18 years) and their caregivers including include parents, guardians, child care providers, after school providers, and teachers. The campaign is designed to reach the target group where they live, work, learn and play using multiple communication vehicles, approaches and channels. The campaign has a spokes-character- the Power Panther and his nephew Slurp to promote healthy eating and to encourage physical activity in children and their families. Power Panther encourages children to eat healthy foods and get more exercise.

Proposed Intervention:
For an intervention for prevention of childhood obesity to be successful, it has to be community-based, involving a community or a social group of people and has to involve social marketing and advertising. [26] However a well recognized potential downside of the community-based programs and social marketing campaigns targeting obesity is their promotion; the social desirability of thinness, which is exacerbated by the media.[27,28,29] Given the uncertainty of the balance between 'benefit' and harm associated with community-based programs and social marketing campaigns, approach to controlling the increasing prevalence of this condition should focus on the benefits of a healthy diet and physical activity rather than on obesity per se. This promotion of a healthy diet and increased physical activity would be expected to lead to the achievement of weight control in current generations, and the prevention of weight gain in future generations. [30]
The proposed intervention will make use of social networks and groups that children and adolescents are a part of in order to communicate healthy behaviors. These networks will involve peers who influence and can be influenced by one another in a way more effective than being influenced by parent, teachers and caregivers. [31] The intervention will also make use of media such as the internet and social networking website which form a large part of the lifestyle of today's children and adolescents. Along with use of social networks, the intervention will use TV advertisements and internet videos to communicate health message to the target audience, who spend a considerable amount of time watching TV and online videos. [32]
In addition to promoting healthy eating and exercise habits, the campaign will also make available fruits and vegetables at more affordable prices to schools who take part in the campaign as well as to families that have children and adolescents. It will involve education of parents and caregivers especially in the lower socio-economic families where healthy eating habits and physical activity are not a part of the household. Along with children, their parents and caregivers will be encouraged to adopt these health practices so that it will be easier for these children and adolescents to Eat Smart and Play Hard.

Critique 1: Psychological Reactance Generated Makes Campaign Ineffective
The ESPH Campaign involves getting children and adolescents to eat healthier and take part in more physical activity. The Campaign does this by telling children what healthy food are and that they must eat these foods. For example telling children to eat more fruits and vegetables, asking them not to drink sweetened drinks, not eat fried foods, etc. In order to improve physical activity i.e making children play hard, the campaign recommends restriction of screen time. This means that parents have to set restrictions for the amount of time spend in front of the TV, computer, video games, etc. [15]
The Psychological Reactance theory proposed by Brehm, states that if a person's behavioral freedom is reduced or threatened with reduction, the person will become motivationally aroused. This arousal would presumably be directed against any further loss of freedom, and it would also be directed towards re-establishment of whatever freedom has already been lost or threatened. This hypothetical state of motivational arousal is know as Psychological Reactance. [16,17] The variables affecting the degree of reactance include, strength of a threat, presence of a freedom, importance of the freedom, proportion of the freedom threatened, and implication for future threat . [18] The effects of this psychological reactance can adversely affect the ESPH campaign. When children and adolescents are told what they must and must not eat, their freedom to select the food of their choice is threatened. They can react to it by intentionally picking so-called the forbidden food. The success of a public health campaign in avoiding reactance, depends on its explicitness, dominance and reason. [19] The ESPH campaign does not explicitly explain to the target audience why they must eat healthier foods. One of the tools is replacing unhealthy foods in the cafeteria with healthier options, but in doing so, there is no consideration given to reasoning with the children and adolescents as to why this change has been brought about. This will result in increased reactance among the children and decrease the chances of changing health behavior. Similarly, with regards to the play hard part of the campaign, if children are made to exercise by enforcing screen time restrictions they will see it as a threat to their freedom. This will increase reactance and they will be prompted to do the exact opposite and not exercise in order to gain back control. [20]

Intervention Defense 1: Using the Social Cognitive Theory/Social Network Theory to Combat Psychological Reactance.
One of the ways to overcome psychological reactance is to make the campaign message delivery as similar to the target audience as possible. This is less threatening to their freedom and they will willingly want to bring about the behavior change. Similarity increases the positive force towards compliance by increasing liking. [33,34] A good way to do this is to have a communicator who is as similar to the children and adolescents. Thus using peers to convey the message of healthy eating habits and increased physical activity will be more widely accepted by these children than a similar message by parents, caregivers, schools, etc. This can be done by building a model based on the Social Cognitive Theory which states that change is behavior is influenced by the environment, self-efficacy and modelling of observed behavior. [35]
In schools, a committee of students can be formed, who will communicate the message of eating healthy and increasing physical activity. The initial group of students can be selected based on general model social behavior, peer influence and leadership potential. This group of students can communicate the message directly to their fellow students and also communicate to the teachers and school management about what children and adolescents like to eat, the physical activities that they would enjoy taking part in, etc. The students can be involved with the school in deciding healthier options to replace junk foods in the cafeterias. This will help schools have foods that are healthy and more liked by children. Also knowing that their peers had a say in deciding the cafeteria menu will reduce reactance among the children and adolescents and they will be more willing to try these new healthier options. Also knowing that the more popular and influential kids eat healthy foods, will make many other children model similar behavior and this will encourage healthy eating habits.
In order to improve physical activity, a similar group of students can be used to help the educators come up with innovative and interesting activities that will be attractive to the students. Team activities can also be started using the selected students as leaders of different teams. There can be healthy competition which will encourage the students to engage in more physical activity without it being boring or seeming like a task. At home this can also be done by encouraging older siblings to first modify and adapt healthier eating habits by explaining to them the importance of these health behaviors. Being explicit and open about healthy eating habits will reduce reactance amongst the older children. [19] They should be told about the influence they have on their younger siblings and that they can act as helpers to the parents. This will evoke a sense of responsibility among the older sibling and will improve health behavior in younger siblings through modeling of sibling eating habits.
In addition to this, the Social Network theory can also be used to improve eating habits and physical activity among children and adolescents. Network phenomena appear to be relevant to the biologic and behavioral trait of obesity, and obesity appears to spread through social ties. [37] This knowledge can be used for prevention of Childhood Obesity. According to the Social Network theory , the factor that most affects a person's behavior is the behavior of persons in their social network, such as family, extended family or non-kin -church or work groups, friends or neighbors who regularly socialize and clubs and sporting teams. [38] This can be done by positively using various social networking websites where children and adolescents are a part of. Groups can be formed on these sites that encourage healthy eating habits and increased physical activity. The campaign can be propagated as a movement, being a part of which, can be considered trendy or 'cool' by the target group. This can again be done by initially involving a select group of students and including them as part of the campaign. They can then spread the message to their network of friends via these websites and these friends will pass it on to others, thus creating a large movement which will spread through the social network. [39] This social network can then also be used to create and organize events that will encourage healthy eating habits and involve physical activities games, among others and targeted toward different age groups keeping in mind their interests and current trends. Various other online contests such as one for healthy innovative recipes that children and adolescents can come up with, games involving physical activity, etc can also be held. Thus social networks can be used to bring about health behavior change.

Critique 2: Use of An Animated Mascot/Spokesperson to Communicate Behavior Messages
The ESPH Campaign uses animated spokes-character, the Power Panther and his nephew Slurp, to communicate messages to children and adolescents and their care givers. The Campaign provides three scripts to help communicate these messages. [21] Eat Smart. Play Hard. With MyPyramid: It is a script for community events and introduces parents, kids and community groups to the Power Panther and the food guide pyramid. It provides an optional physical activity- Power up Moves.
Power Panther takes Eat Smart, Play Hard to Schools: This is an interactive session where school-age children are introduced to Power Panther who encourages them to embrace healthy eating and physical activity behaviors. Power Panther also conveys the importance of eating breakfast. Learn to Eat Smart, Play Hard with Power Panther: Interactive session where children and care givers are introduced to the campaign
Along with these scripts, there is also a Power Panther song encouraging children and adolescents to follow healthy eating habits and physical activity.
The target audience of this campaign is children and adolescents from 2 to 18 yrs of age. While use of an animated character as a spokesperson may be an effective means to communicate with younger children, it may have an adverse effect on adolescents. Adolescents do not like to be treated like children. They are at a stage when they begin to consider themselves close to being adults and prefer to addresses similarly. Often reckless and irresponsible behavior seen in teenagers is a way of declaring their adulthood. If they are treated as adults by caregivers, teachers, etc., they almost immediately rise to the challenge and can bring about effective behavior change. [22]
The ESPH campaign mainly uses tools such as activity sheets, bookmarks, comic stickers to encourage children to indulge in healthy behaviors. They also use brochures, posters and handouts. Though attractive to younger children, these tools may not be an age-appropriate method to communicate with adolescents. Adolescents are less likely to take these methods seriously and may in turn mock them or form spoofs to gain peer popularity. This deters the goal of the campaign. Also adolescents are at a stage where they tend to look up to their peers and gain recognition from them and are less likely to be influenced by a spokes-character like the Power Panther which they might consider too childish for them. [23] In order to gain prestige some teens use general sociability and good reputation while some others do it by being the class clown. [24] In attempting to be popular among peers these teens might resort to mocking the seemingly juvenile posters, stickers, etc.
This can result in others following similar behaviors due to peer influence and not taking the campaign and its message seriously. [25] For the campaign to be successful, it needs to be conveyed via a more effective vehicle that is likely to be effective for all of the target audience.

Intervention Defense 2- Use of Advertising and Marketing Theory for Better Compliance.
An important cause of increased childhood obesity is in the increase in junk food TV commercials. [39 ] These commercials are based on the three main principles of the Advertising theory. They are:
Promise: Every advertisement makes a promise to a certain desirable outcome to the consumer if he/she buys the product
Support: Evidence that the product can support the promise
Core Values: There are a certain set of core values that have universal appeal.
Some of these are family, love, freedom, youth, rebelliousness, power and, acceptance. If an advertisement can appeal to these values in an individual, it is more likely than not to be successful.
These same principles can be used to create advertisements which encourage healthy eating habits and physical activities in children and adolescents.
Advertisements can use young celebrities who can communicate the Eat Smart, Play Hard message. These celebrities are usually looked up to by children and adolescents and have high model prestige. If they encourage a certain health behavior, more youth will want to model their behavior and indulge in healthy eating and exercise habits. The advertisements can be as simple as the celebrity choosing a fruit or a vegetable over a bag of chips. They can be targeted towards appealing to the core value of 'power' where children will believe that it is indeed in their hands to make a change about their own behavior and whether or not they choose a healthy lifestyle is up to them. This will also minimize psychological reactance and bring about voluntary change in health behavior.
In addition to using celebrities, children and adolescents from the same age group as the target audience can be used to create advertisements that promise a healthy life style. For example, an advertisement can show a group of teens, including a mix of different type of kids that most children can identify with. These teens can be shown to make simple choices such as picking health food at the cafeteria, choosing to bike to school or even the mall as opposed to being dropped off, choosing to play a group sport as opposed to a video game and doing so with a lot of ease and enthusiasm. Each of the advertisements can have the catch phrase 'I/We Choose', followed by different endings such as 'eat healthy', 'stay fit', 'go green'. These will appeal to a number of core values such as freedom, power, rebelliousness, acceptance just by demonstrating that children and adolescents have the power 'to choose' the right health behavior. Media, in the form of, attractive visuals and catchy music can be used to appeal to these youth along with using the factor of peer influence. [31] This will create a public health brand that will seek to change eating and physical activity habits.
Social Marketing employs commercial marketing principles and tactics to influence voluntary human behavior for societal benefit rather than commercial profit. [42] According to this marketing theory, there is a need to research what consumers want and modify the campaign so that the product trying to be sold fulfills those wants. These ads will market 'Fun and Freedom' in order to promote good health. The advertisements will make the promise of a healthy yet fun and interesting lifestyle appealing to various core values in youth. In order to follow up and provide support to this promise, we can have healthier options in cafeterias, more time allocated to physical activities in schools, providing parking for bikes at schools, malls etc. In addition to having advertisements on TV, the videos can also be posted online. The internet is one of the major sources of entertainment and learning for today's youth. Children and adolescents spend a good amount of time surfing the internet. [42] Thus putting these videos online can increase their viewership in children and adolescents.
The internet can also be used to create various competitions under the 'We Choose' campaign where children can send in videos and photographs of their friends and peers and how they chose to make a healthier food or exercise choose. This can be done through social networking sites as well as online videos announcing these competitions. Winners will be chosen from each category on a monthly basis and winning videos and photos can be posted online and at the end of 6 months one chosen video can be used as a part of a TV advertisement. This will create healthy competition as well as provide an opportunity to do something creative, all while keeping the ultimate goal of healthy eating and exercise habits.

Critique 3: Reliance on the Theory of Reasoned Action Fails the Campaign at a Community Level
Like a lot of other public health interventions, the ESPH Campaign relies on the Theory of Reasoned Action. According to this theory, a person's behavior depends on [43]:
Attitude: A persons belief about what will happen if he or she performs the behavior and a person's judgment about whether the expected outcome is good or bad.
Subjective Norms: A person's belief's about what other people in his or her social group will think about the behavior and a person's motivation to conform to these perceived norms.
Behavioral intention: A person's intention to perform behavior.
This theory however has its weaknesses. To begin with, it is an individual level model, which assumes that intention leads to behavior which may not be true. It also uses social norms as a determinant for behavior change. However social norms are not universal and defer based on culture, society, etc.
The ESPH campaign involves use of charts, posters, worksheets etc to explain to children and adolescents the importance of healthy eating and physical activity. Through the use of its spokes-character it encourages adoption of such health behaviors. However, the theory makes an assumption that if children know the health benefits of healthy eating and exercise they will want to change their habits and this in turn will prevent obesity and bring good health. However there are various other factors that may be barriers to adoption of healthy behaviors even if children and adolescents intend to do so. One of the ways the campaign plans to promote healthy eating is providing healthier options in the cafeterias. However it does not take into account the fact that often these healthier foods such as fruits, vegetable or salads are more expensive than the unhealthy options, such as a bag of chips or French fries. [44] Though some children may be able to afford these more expensive food items, there are many that may not be able to do so and therefore their intention to eat healthy may not actually turn into reality.
Another problem would be eating habits of children after school. Many children come from families that do not themselves practice health eating and exercise habits at home. For these children the unhealthy habits are a part of their lifestyle and they view them as norms. Since they think this is normal behavior, it is harder to them to bring about a change in their behavior. Also often children and adolescents come from poorer families who cannot afford to buy healthier foods. There are also children whose parents themselves are not aware of the changes that can be brought about with addition and healthy food and exercise behaviors and unhealthy habits for such children is often learned behavior. The Campaign however assumes that parents would actively take part in bringing about change to their households with the use of tools provided through the campaign. The campaign does not take into account these norms that affect the child's behavior and does not involve active education of parents and caregivers.

Intervention Defense 3: Overcoming Assumptions of the Theory of Reasoned Action.
In order to enable children and adolescents to adopt healthy behaviors, the campaign will provide affordable healthy foods. The Campaign will match prices of foods such as fruits, vegetables, salads, etc to those of unhealthier options like fried and fatty foods. This will enable children to make a choice without having to worry about the costs involved in choosing healthy foods. This can be done by partnering with produce companies and buying in bulk so that affordability of these foods can be maintained. In addition to this, the healthier foods can be displayed more attractively and accessibly so that young people who have the intention to change their health behaviors will get a push forward in the direction towards making that healthy choice.
Another barrier to adoption of healthy eating and exercise habits is the after school environment of kids which differs from person to person. The Campaign will undertake education of parents and caregivers by conducting community level programs and workshops. In these workshops the parents and caregiver will be taught about the ill effects of obesity during childhood and its affects on future life as adults. Benefits of healthy eating habits and regular physical activity will be explained to them and they will be given various methods to help bring about this health change in their wards. They will be given various easy healthy recipe options and encouraged to incorporate these into their diet. They will also be told not to ask a certain behavior of their children in order to avoid reactance but instead to provide healthy options to the children and encourage them to make the right choice. For families who come from lower socio economic backgrounds, healthy foods such as fruits and vegetables will be provided at subsidized rates within the community and incentives will be provided to families that adopt healthier eating habits.
To encourage regular physical activities, parents and caregivers themselves will be encouraged to take part in such activities and use some such fun physical activity as a good bonding experience for the entire family. Adults will be encouraged to adopt healthier lifestyles and lead by example by cutting down on screen time themselves. This will help create an environment which will prompt children to take up more physical activity. [45] Parents will also be educated to encourage their children to walk and use bicycles to go to school and other accessible places rather than dropping them there. The campaign will organize community events where families can take part in activities such as races and other games involving physical activity, workshops for parents and kids to learn simple and healthy recipes, etc. These will help bring about effective health change in children and adolescents.

Conclusion:
Current interventions for prevention of Childhood obesity include the Eat Smart, Play Hard Campaign which is targeted at children and adolescents between 2-19yrs of age. It makes use of tools such as worksheets, charts, posters, spokes-character, etc to encourage children and adolescents to adopt healthy eating habits and physical activity. This campaign however, does not take into the account the psychological reactance that it cause in youth, does not use enough and appropriate mass media to propagate its message and does not take into account the various barriers to adoption of the suggested health behaviors.
The new campaign that this paper proposes, plans to overcome the drawbacks to the ESPH Campaign to create an improved childhood obesity prevention program. The new campaign makes use of celebrities and peers to communicate the health messages in order to minimize reactance. It makes use of the power of social networks in influencing youth and uses them to bring about behavior change. It uses TV and online advertisements which appeal to core values of the youth and gives them the power to choose to adopt the target health behavior thus prompting informed change and promoting the adoption of a healthier lifestyle. The campaign also makes an effort to overcome economic and social barriers that may limit children from eating healthy and taking up more exercises. It does this through parent and caregiver education and provision of healthy foods at subsidized rates to participating schools and families with children and adolescents.
Child Obesity is one of the leading public health problems in the US today. It has serious short-term consequences such as increased risk of developing high cholesterol, hypertension, respiratory ailments, orthopedic problems, depression and type 2 diabetes as a youth [46]and long term consequences such as increased risk of diabetes, high blood pressure, high cholesterol, asthma, arthritis, and a general poor health status. [47] Prevention of Childhood obesity should therefore be a public health priority. The new campaign proposed, aims to prevent childhood obesity by a using more effective vehicles to promote health behavior change and if well implemented will help bring the obesity epidemic under control.

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The Patient Protection and Affordable Care Act: Menu and Vending Machine Labeling. Will Consumers Digest The Information? – Crysta Jarczynski

The Problem
Obesity is a heated topic these days in the world of public health. From community interventions, to policy, to first-lady-led movements, citizens of the United States likely hear something about the issue a few times a week; and for good reason. The prevalence of unhealthy weight in adults is high: over 30% of adults are obese (BMI30) and 68% of adults are overweight (BMI25) (1). 20.1% of males and 17.3% of females ages 6-19 have a BMI in the 95th percentile (2). Obesity is associated with an increased risk of diabetes, hypertension, dyslipidaemia, heart disease, cerebrovascular disease, obstructive sleep apnoea, asthma, gastrointestinal system complications, osteoarthritis, cancer, psychosocial dysfunction, gynecological and obstetric complications, surgical complications, chronic kidney disease, and death (3). So one can see why such a health concern is on the national radar at this time. According to the Centers for Disease Control and Prevention (CDC), there are many factors that can lead to obesity, including eating too many calories, not getting enough physical activity, genetics, behavior, environment, culture, and socioeconomic status (4). This may explain why there are so many varied approaches to combating obesity.
One specific contributor to obesity is the availability of high calorie and sugary foods outside of the home. According to the National Health and Nutrition Examination Survey (NHANES) from 1999-2000, 41% of the population reported eating commercially prepared foods three or more times weekly, and higher eating-out frequency was associated with adverse nutritional consequences (5). A survey done in New York City found that one-third of lunchtime purchases were over 1,000 calories. Shockingly, “combination meals” at hamburger chains accounted for 31% of all purchases, and averaged over 1,200 calories (6). Vending machines, another form of eating away from home, are also contributing to poor eating habits, especially because of their availability in schools. Even though some schools have taken action to combat this problem, foods and beverages offered in vending machines continue to be high in fat and calories (7). Food consumed outside of the home is a big problem area in the obesity epidemic, so the federal government took steps to solve that problem.

The Solution: The Patient Protection and Affordable Care Act
The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 30, 2010. Section 4205 of the PPACA was created to address some of the issues mentioned above. The first part of Section 4205 requires nutrition labeling of standard menu items in restaurants and similar retail food establishments. In order to be covered by the requirements, restaurants and similar food establishments must be:
part of a chain with 20 or more locations,
doing business under the same name, and
offering for sale substantially the same menu items in their different locations (8).

Qualifying establishments are required to list calorie content information on standard menu items on restaurant menus and menu boards, including drive-through menus. Additional nutrition information, including total calories, fat, saturated fat, cholesterol, sodium, total carbohydrates, sugars, fiber and total protein, must also be available in writing upon request (9).
Vending machines are included in Section 4205. Any business owning or operating 20 or more vending machines must display the calorie information for the food inside if the nutrition labels on the food packaging are not visible from the outside. Specifically, the calorie count must be displayed in close proximity to each individual product inside or the selection button (10). Any restaurants, similar retail food establishments, and vending machine operators not covered under the requirements may voluntarily register to be covered. The Food and Drug Administration hopes that having caloric information visibly displayed will help consumers make healthier food choices (11).

Does Action Follow Intent?
Section 4205 of the PPACA is based on the health belief model. The health belief model centers on the idea that a cue to action will cause people to consider if they are susceptible to a certain outcome and how severe that outcome will be. Then they compare that susceptibility to the benefits and barriers of engaging in the behavior. From that, they build an intention and the action logically follows (12). The health belief model applied to Section 4205 would look something like this: Andy goes to a fast food restaurant and is about to order a cheeseburger combo, when he notices that it has 1000 calories. He remembers hearing somewhere that he should have 2000 a day and he’s surprised that this is half of his daily recommended value. He thinks about the risks of eating too many calories: heart disease, specifically, because he has a family history. He feels susceptible because his grandfather died of heart failure, and he thinks death is severe. He then considers the benefits of eating a lower calorie meal, mainly his good health. The barriers are low because there are some 700-calorie meals on the menu and they look adequate. He intends to eat a lower calorie meal and then chooses the lower calorie meal.
This seems like a plausible method, but the health belief model takes a few things for granted. The first big assumption is that consumers will make a rational decision (choosing a lower calorie meal) based on their intention (to eat healthier). The model, and therefore Section 4205 of the PPACA, is placing a lot of confidence in the individual’s self-control to stand by that intention when faced with the alternative of instant gratification. The negative effects of a high calorie diet are often long-term and so not of as much importance in the immediate moment. When given the option of instant gratification—choosing to eat whatever one desires at that moment—a person must practice self-control. Unfortunately, people tend to over-indulge in activities with immediate rewards and delayed costs (13). While providing the calorie information for food items may increase healthy choices some of the time, they may cause a rebound affect of binge eating or create feelings of guilt in people who continue to choose higher calorie food.
Consumers may also irrationally believe that they are not susceptible to the negative outcomes of eating a high calorie diet. Most people can recall a friend or family member who lived well past their expected age, despite participating in risky health behaviors. Since numbers on a menu lack any context, people will more likely recall stories they are familiar with and feel some connection to (14). These unframed numbers are competing with a world of context and familiarity around these high calorie foods, which has been created through advertisements. Adolescents have a specifically optimistic thought process when it comes to risk behaviors. When deliberating on whether or not to engage in a certain activity, in this case eating high calorie food, the teen brain tends to focus on the benefits, i.e. eating whatever they want, rather than the costs (15). When irrational optimism is at play, displaying caloric content will have little effect on decision making.

Are We Alone in Our Decisions?
The health belief model is an individual level model, and therefore Section 4205 puts the responsibility of choosing a lower calorie menu option entirely on the individual. The reality is that people do not live and, more often, do not eat in a social vacuum. This can cause the intended behavior to backfire for a number of reasons. Social modeling plays a key role in deciding whether or not to participate in a particular health behavior (15). If a person is deciding what food to order in a group context, and that group does not value eating a lower calorie diet, the person may be reluctant to choose a lower calorie food, especially if they already want to indulge in their favorite meal. The fact that they are following the herd makes it easier to make a potentially unhealthy decision because they are not alone in this decision.
Another social factor that may impede the decision to eat lower calorie meals is the perceived societal value of that decision. The media plays a large role in creating these social norms (15). Although diet solutions are portrayed in the media, there is also a juxtaposition of effortless weight control. Often, slender people are portrayed as naturally slender, and therefore can eat whatever foods they want. Conversely, most of the time it is the overweight person shown trying to change or control his or her weight. This attaches a certain stigma to weight control, creating the image that only overweight people are unhappy with their bodies count calories and display other food-related health concerns.
Because of these media images, it is likely that cue to action—calories on the menu—will evoke thoughts of weight control. Even though there are other negative side effects to eating a high calorie diet that may manifest outside of weigh gain, this policy lacks a frame; therefore the individual will create one based on social norms. The media-influenced frame carries a stigma and may impede the intended behavior by making someone who chooses to count calories feel like the only person trying to maintain a healthy weight. According to the media, this society values slender bodies that are kept that way with ease, and stigmatizes weight watching.
Given the increasing public health focus on obesity, it is likely that many young people have experienced some form of nutrition education. Because of this, they may choose to react to the cue to action by doing the opposite of what they have been taught. The nutrition education suggests how to eat healthy and that may feel like a threat to the young person’s freedom, so s/he may choose to rebel (16). This rebellious behavior may be magnified by the presence of peers, at which point choosing to order higher calorie food may become competitive. This links back to a social norm among many adolescents: that they are just too cool to care about health.
What Do (and Should) Calories Mean to Children?
The part of Section 4205 that applies to vending machines has the same weaknesses mentioned above but there are some separate flaws, given the prevalence of vending machines in schools. One study in Minnesota evaluated 20 secondary schools and found a median of 12 vending machines per school (17). As mentioned above, Section 4205 requires that vending machines display calorie numbers without providing any sort of context. This is already less effective with adults who may know something about calories, but many children have no frame of reference for the numbers they will see in the vending machines.
A review done by the World Health Organization found some striking results about food promotion to children. Advertisements targeting children seek to establish brand loyalty from a young age. Food advertisements aimed at children are outnumbered only by toy advertisements, and are received through television, the internet, and print/signage. The “big four” in food promotion are sugar sweetened breakfast cereal, confectionary products, savory snacks, and soft drinks. Multiple studies found that advertisements had an effect on food behavior that was equal in importance to the effect of family, parents, and peers (18). Three of the “big four” in food advertising aimed at children are commonly found in vending machines. Displaying calorie information without any context will have an insignificant impact compared to the familiarity children feel from seeing certain foods in advertisements (14), and therefore children will continue to make their food choices based on these advertisements.
The fact that children do not have a frame of reference for calories is a good thing. Introducing the idea of calories to young people can create a disordered way of looking at food. For instance, Lara Pence, a clinical psychologist from Renfrew, an eating disorder treatment center in Dallas, explained that new smartphone applications that count calories are feeding into the eating disorder mentality of obsessively controlling food intake (19). Such applications encourage hyper-monitoring of calorie intake. Posting calories on vending machines without any context may alert children to a way of thinking about food that leads to unhealthy food behaviors. Research also suggests that parental eating patterns influence a child’s eating patterns (20). The sudden increase in visual calorie cues may increase conversations about calories that could negatively influence the eating habits of young people.

Recommendations to Address These Weaknesses
While Section 4205 was created with noble intentions, it is simply not adequate enough to change the desired behavior on its own. This public health intervention is a special case, however, because it is policy-based and there are limits to what Congress can mandate food retailers to do. While there may be creative methods to address the flaws listed above through policy, there is also the options of partnering with various departments, non-profit organizations, or research projects. For instance, in 2010 the Department of Health and Human Services partnered with the HealthySocial Project, created by Children’s Hospital Boston and Harvard Medical School (21). Together they developed a Facebook application called I’m a Flu Fighter! which allows Facebook users to tell their friends that they were given their flu shot and find more information about flu vaccines in their area (22). A similar approach could make Section 4205 a more effective public health campaign.
A Facebook or smartphone application could potentially make choosing healthier menu options more fun and social. When the application is first downloaded, the user is primed with a short survey that can also be used for research purposes. The survey includes some demographic data and then the prime, “Do you intend to eat lower calorie meals when you eat out?” The mere-measurement effect tells us that asking this question of users will increase their likelihood of acting in a way that corresponds with their intentions (23). The last part of the short survey is a question about receiving further information via email. The material sent through email serves as a visual cue to keep users informed of their intent to eat lower calorie meals when eating out.
The application itself is rather complex and will take some cooperation on the part of fast food restaurants. The idea is that when a person eats at a restaurant chain, they receive a code on their receipt that corresponds with the calories in their meal choice. The user then enters any codes into the application and is awarded points based on their meal choices. The application does not keep track of actual calories consumed, nor does it display these calories anywhere. It will instead operate on a point system such that more points are awarded for lower calorie meal choices. The points are also adjusted depending on the number of times the person is eating out within a given time period. This adjustment is based on the assumption that meals consumed at home are generally healthier than meals consumed outside of the home. For example, if a person chooses a lower calorie meal and has only eaten out once in the past week, s/he will receive more points for that meal choice than for someone who chooses the same meal but has also eaten out four times that week. No one but the user knows how many times s/he has eaten out or the calorie content of the chosen meals.
The points awarded for meal choices are then used to earn badges for the user’s profile and to interact with others in a game. The success of games such as Farmville and Pet Society suggest that basing a game on building a virtual world of some kind would be an addictive and enticing way to approach this campaign. Perhaps the points that players earn from choosing lower calorie meals can be used to build an online restaurant. Then the players can take their healthy food choices a step further by choosing to sell healthier foods in their virtual restaurants. It may be a challenge to get restaurants on board with the point system at first, but there would only need to be one or two well known chains involved in the beginning stages. Those restaurants will start by giving point codes and advertising, and then the application will grow in popularity. Once it goes viral, or reaches a “tipping point,” the application will gather enough users to make it profitable for more restaurants to provide point codes on receipts (24).
The application would compliment Section 4205 by addressing some of the weaknesses previously mentioned. First, it would provide an intervention that does not rely on rational thought. While consumers would hopefully have some awareness of the health benefits of choosing lower calorie meals, health would no longer be the primary incentive for choosing those meals. With the application, consumers would be motivated by social incentives. The points rewarded would act as a stimulus to reinforce the desired behavior, choosing a lower calorie meal, and therefore consumers would be driven to acquire points and compete with their peers (25). The application would also replace the long-term benefits of health with a more short-term motivator, winning points for the online game. This would take care of the issue of instant gratification because it would be much more reasonable for a person to put off choosing a meal they desire that might have higher calories for the reward of going home and entering their points.
The application addresses these weaknesses by creating a social network that supports and encourages communities to strive together to eat lower calorie meals, even if the incentive is not health. It changes the norms around healthy eating from stigmatized or not important, to fun and social. While the norms are not directly changing, the behavior is changing by way of incentive. When an individual is part of a social network, s/he begins to pick up and perform the dominant behaviors as they spread through the network (26). The social network diminishes individual responsibility for food choices and replaces it with a group level behavior change. While both adults and children/adolescents use Facebook and smartphone applications, teens will most likely have a higher exposure to the norms of the social network. This will increase their familiarity with the idea of eating healthier foods and therefore decrease the likelihood of reactance (16). If enough people use the application, the perceived societal value of eating healthier meals will increase such that even people who are not using the application will follow the new norms. It is much more efficient to rely on people to spread behavior change through a network than to count on each individual to change on their behaviors alone.
Including vending machines in Section 4205 is an incomplete approach to addressing the problem of obesity, as well as potentially risky to children. Providing calories without any context could lead to disordered ways to look at food. The World Health Organization’s review of food advertising for children found that most food marketing uses themes focused on fun, fantasy, and novelty (18). If Section 4205 hopes to compete with these advertising techniques, it would be wise to approach vending machine requirements from a similar angel. Instead of displaying calories next to foods in vending machines, the vending machines themselves could become interactive. For instance, vending machine products could be stocked in such a way that lower calorie foods and drinks are in the top rows and higher calorie options are in the bottom rows. Then when a person, or more specifically a child, buys an item from the top shelf, the machine lights up and plays a tune. As the purchases move down the rows, the response to the purchase becomes less and less exciting, until the bottom row where there is hardly any fanfare at all.
Interactive vending machines would supply a context for food purchasing that children can relate to. Since the calories would no longer be the primary focus of the purchase, it removes the danger of creating an unhealthy obsession of calorie counting at a young age. Instead, children will begin to associate healthier, top-row foods with feelings of fun, excitement, and fantasy. These associations will create a new form of brand loyalty based on healthy eating. Policies like Section 4205 could instead regulate what requirements vending machine foods must meet to be considered top-row items. Section 4205 cannot require vendors to get interactive vending machines, but they could perhaps provide incentives to vendors who invest in these machines.

Conclusion
Section 4205 of the Patient Protection and Affordable Care Act is, in most ways, a positive direction for the U.S. to be heading in. However, alone it cannot accomplish the desired behavior change of choosing healthier foods, and in some cases it runs the risk of creating unhealthy relationships with foods. If the proponents of the PPACA instead, or additionally, invested their budget into changing the social norms surrounding healthy food consumption, they would have a much larger impact on the health of the country. It would be beneficial to invest in intervention methods that make purchasing healthy foods while eating out fun and socially valued, in addition to the menu and vending machine labeling requirements.

References
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Malnick SDH, Knobler H. The medical complications of obesity. Oxford Journals 2006; 99(9): 565-579.
Centers for Disease Control and Prevention. Overweight and Obesity: Causes and Consequences. Washington, DC: CDC. http://www.cdc.gov/obesity/causes/index.html
Kant AK, Graubard BI. Eating out in America, 1987-2000: trends and nutritional correlates. Prev Med 2004; 38(2): 243-9.
Dumanovsky T, Nonas CA, Huang CY, Silver LD, Bassett MT. What people buy from fast-food restaurants: caloric content and menu item selection, New York City 2007. Obesity (Silver Spring) 2009; 17(7): 1369-74.
Pasch KE, Lytle LA, Samuelson AC, Farbakhsh K, Kubid MY, Patnode CD. Are school vending machines loaded with calories and fat: an assessment of 106 middle and high schools. J Sch Health 2011; 81(4): 212-8.
U.S. Food and Drug Administration. E-Docket: Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar Retail Food Establishments. Washington, DC: FDA. http://edocket.access.gpo.gov/2011/2011-7940.htm
U.S. Food and Drug Administration. Questions and Answers on the New Menu and Vending Machines Nutrition Labeling Requirements. Washington, DC: FDA. http://www.fda.gov/Food/LabelingNutrition/ucm248731.htm
U.S. Food and Drug Administration. E-Docket: Food Labeling; Calorie Labeling of Articles of Food in Vending Machines. Washington, DC: FDA. http://edocket.access.gpo.gov/2011/2011-8037.htm
U.S. Food and Drug Administration. Questions and Answers on the New Menu and Vending Machines Nutrition Labeling Requirements. Washington, DC: FDA. http://www.fda.gov/Food/LabelingNutrition/ucm248731.htm
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Christakis NA, Fowler JH. The Spread of Obesity in a Large Social Network over 32 Years. The New England Journal of Medicine 2007; 357(4): 425-34.

Failure of “Above the Influence”, an Anti-Drug Campaign – A Critical Analysis - Yash Mehta

In 1998, the Office of National Drug Control Policy (ONDCP) launched the National Youth Anti-Drug Media Campaign, the largest of its kind with the overall goal “to educate and enable America’s youth to reject illegal drugs, to prevent youth from initiating use of drugs…and to convince occasional users of these…to stop using drugs” (1-3).

Initially designed as a five year-one billion dollar campaign the movement continues to this day and has been subject to a lot of critique (4). The use of brand in the NYADMC for teens first took shape as “My Anti-Drug,” which entailed messages encouraging youth to avoid drugs. In 2005, the NYADMC was rebranded “Above the Influence (ATI)”, a brand that incorporates greater information about the social influences, exposure, and pressures that may play a critical role in the initiation and continuation of adolescent drug use (5).

The “Above the Influence” campaign reaches out to adolescents via an official online website (www.abovetheinfluence.com), a collection of television commercials, and magazine commercials which were all designed to make teens in America more aware of which factors most strongly influence the decisions they make (6). The campaign also claims to reflect what teens nation-wide have reported is going on in their lives regarding peer pressure, stress, and self-control (6). However, despite the “Above the Influence” campaign’s attempts and efforts to minimize drug use among the American youth, ample evidence supports that the campaign has been ineffective and perhaps even counterproductive, “leading those exposed to an increased perception that others use marijuana” (7).

“Above the Influence”, an improved version of the original ‘My Anti-Drug’ campaign hasn’t produced the projected results; according to the results of the 2009 Monitoring the Future survey indicate that 15.7% of eighth graders, 32.3% of tenth graders, and 42.0% of twelfth graders reported lifetime use of marijuana. In 2008, these percentages were 14.6%, 29.9%, and 42.6%, respectively (8). One of the main reasons why “Above the Influence” campaign didn’t work was because of its combined reliance on Cognitive Dissonance and the Health Belief Model. These theories have received major criticism over the years and have not been able to accurately predict predicting or controlling people’s behavior (9). Another major flaw of the campaign is that it sends out are negative and mixed signals, the campaign focuses on the harmful effects of marijuana and alcohol use (both used excessively) and tries convey the message in a very cryptic way, which doesn’t help too much. Also, the prime gaffe they make is telling kids who are under the influence, ‘what to do’, which according to the Psychological Reactance theory is the biggest mistake public health campaigns make (10).

Research proving the campaign failed

Westat conducted a large study from 1999 to 2004 which looked at reported changes in attitudes, beliefs and behavior of parents and children with regard to drug-usage and compare these with self-reported measures of media exposure. They also wanted to investigate what kind of an association existed between the attitudes and beliefs held by the parents as compared to those of their children and look at what changes might be prevalent on the basis of the “Above the Influence” campaign. The study finally examined the effects of the campaign by comparing groups of people with high exposure to groups with low exposure to the commercials (11). They collected data longitudinally from a group of participants and assessed whether a relationship existed between usage of drugs and exposure to campaign advertisements and if there was any effect of the latter on the former. Their results showed that when non-drug-using youth in America were exposed to the “Above the Influence” campaign, “greater exposure to the campaign was associated with weaker anti-drug norms and increases in the perceptions that others use marijuana” (11). They found that there was a positive relationship between campaign exposure and the resulting effects on parental beliefs and attitudes; however it did not correlate with affecting the attitudes, beliefs or behaviors of the children. Their reported, thus suggested that the “Above the influence” campaign had been counterproductive. Houston also refers to campaigns within the White House’s Offices of National Drug Control Policy such as the “Above the Influence” campaign as “wasteful, misleading, and ineffective anti-marijuana campaigns” (12). With all the converging evidence proving that this campaign has only been flawed and not useful for the context in which it was meant to affect the behavior regarding drug use, it is important to look at different ways to reform the same campaign and recognize the pitfalls and work on improving them to make a stronger campaign that will reach out to the intended consumer and bring about the desired change.

Why did “Above the Influence” campaign fail?

Use of wrong theories

Among many other reasons, the reliance on the combination of the Theory of Cognitive Dissonance and the Health belief Model has been a reason in the failure of the “Above the Influence” campaign. While the Theory of Cognitive Dissonance forms the basis of the television and the advertising through various media, the online site lays its foundation on the Health belief model.

Leon Festinger, created the Cognitive Dissonance Theory. This theory states that when a person’s attitude is different from his behavior about something, there is a state of dissonance. This dissonance causes the person to either change his attitude or his behavior to reduce that dissonance. To try and understand this dense statement, we should know that Festinger believed that deep in their psyche, humans needed to be in line with their attitudes and behaviors. We humans want to be unified in “thought and action”. When we counter disharmony or inner conflict between what our beliefs we strive to decrease this tension by either “changing our original thought, giving strength to the opposing thought, or letting go of the behavior” (13). On these lines the current commercials are not promoting a product but rather trying to encourage a behavior change, instead of an attitude change.

The main mistake the campaign makes is that while trying to sell the idea of ‘not doing drugs’ and to make a child take the right decision of choosing to remain sober, they create confusion and vaguely even de-motivate the child from changing his behavior and adapting an attitude change.

The Health Belief Model is psychological and attempts to predict and explain human health behaviors by focusing on an individual’s attitudes and beliefs (14). According to the Health Belief Model, an individual’s health behavior is motivated by four factors: perceived susceptibility (of a health problem), perceived severity of the potential health problem, perceived benefits of an action, and perceived barriers of taking that action (15). One of the biggest problems with the HBM theory is that it primarily focuses on individual decisions and doesn’t address social and environmental factors. What HBM assumes in an internal, rationale process where individuals assess their degree of risk and make a cost-benefit calculation about whether or not to engage in certain behavior, for e.g., intake of alcohol or drugs (16). But these behaviors will vary based on different kinds of information, motivation, interpretations made and the maturity of the individual. For example; a teenager’s intake of alcohol or drugs even after knowing the harmful side effects does not explain the Health Belief Model (16). This is where HBM fails miserably. In reality, it has been observed that people behave in predictably irrational ways and make decisions spontaneously (17). HBM fall flat in addressing to a larger population because it pre-dominantly focuses at an individual. The website of “Above the Influence” campaign is pre-dominantly based on the health belief model. The website provides an individual with all the information about alcohol and drugs and also schools them in the adverse effects of all these drugs. The website goes to the extent of mentioning the street names of all these drugs, which is not of the better things about the website.

A failed ad-campaign

Many of the messages designed by “Above the Influence” (such as the commercial where the girl who is high has a dog that talks to her, and begs her to quit using ), seem to be aimed at middle school aged youth. Talking dogs and flattened people are not realistic, and savvy teens know this and see these commercials as yet another scare tactic commercial, such as the egg “and this is your brain on drugs ” commercial from a decade ago (18). In order for these commercials to be effective, they should not exaggerate the truth, because when they do, they are alienating their target audience.

The Pete’s couch commercial shows three boys sitting on a couch, one of them starts talking into the camera. As the commercial progresses the back drop keeps changes according to the subject the boy talks about.

“I smoked weed and nobody died. I didn’t get into a car accident; I didn’t drown in some swimming pool, I didn’t OD on heroin the next day. Nothing happened. The boy describes how he felt like Pete’s couch is safe and he isn’t really going to die on it. Also, he says how it keeps you safe from the truly scary things out in the world, those being simple pleasures of life like playing with friends, or taking a girl out. But, instead you choose the safe way out. He ends it with saying that he smoked weed but did not die, but in the bargain missed out on the actual important things in life (19).

Again, the problem with this ad is that teens will counter act saying that they love this feeling of sitting on the couch and being in trance. They might react by saying this ad doesn’t apply to help because they are not frequent users of these drugs. Some teens more experienced users might say that those eleven hours are the best of their lives (20). ‘Take my chances in the real world’ gives rise to an instant feeling of poetic sarcasm (which makes me smile), but it doesn’t really strike as something that would make someone not do ‘weed’. The logical reaction by any non-frequent user would be that there is enough time to play basketball and ice-skate even after wasting those eleven hours. But then again, eleven hours is a little too extreme, isn’t it? Also, some might find their freedom to choose under threat and hence react by doing just the opposite i.e., doing weed (21).

The "Stage Hands" commercial is the one where most of the people at a party are attached to strings and some music starts which causes all of the stringed people to dance while a few who aren't attached to strings watch. Then all the dancers fall to the ground and the commercial ends with the logo and website address (22). Again, even in this commercial tries to show such radical effects of drug/alcohol intake that it is almost unbelievable. From a creative point of view the commercial does make a lot of sense, but these commercials are made to manipulate, force or motivate teens out of something they find ‘cool’ and ‘relieving’; intake of drugs and alcohol. Also, this might lead to psychological reactance, and motivate teens to intake drugs only to prove a point; that they are not like the puppets shown in the commercial. At the end of the ad after all the so-called under-influence ‘stage-hands’ fall down leaving only four people (presumably not under the influence of drugs), a voice says “If you are not in control, who is?” This could also be interpreted as “if you are not under the influence, you might be left alone, because everyone is doing it!”

Website gone wrong

A third example of a mixed message sent out by “Above the Influence” is their list of reasons why people do drugs, which can be found on the campaign’s website (23). This message is counterintuitive in that teens are being told not to use drugs, yet they are being bombarded with reasons why people their age are using drugs. If teens are on the website and come across this long list of reasons, even if the reasons are negative and/or do not necessarily apply to their own personal life, teens will be more likely to believe that lots of people are using drugs, which was previously confirmed in Westat’s study (11). If public health campaigns aim to successfully reach out and send a message across to youth in efforts to manipulate their knowledge, beliefs, attitudes and behavior, these campaigns need to do more than merely provide health facts and negative, mixed messages. The message should be positive, clear, and concise. The underlying reasons behind why company brand products are noticed, retained and popular are hidden within the message of the company’s advertisement. Figuring out what type of message attracts the American public to a particular brand product advertisement is crucial to designing or improving a public health campaign.

Above the influence campaign (A failure) - Conclusion

Teenagers smoke weed. They smoke weed because it makes them feel good. They know about the harmful effects of weed and alcohol. As mentioned in this paper the information about the harmful effects of drug use and alcohol consumption are present all over the internet. Above-the-Influence advertisements take the information and creatively try to portray drugs and alcohol as something completely negative and bad in an attempt to try and get kids to avoid using either.

Anti-Drug Campaign improved through the Psychological Reactance Theory

Research and evaluations of the on-going public health programs have affirmed the value of using specific communication strategies to promote health and prevent disease(24). Effective strategies combine theories, frameworks, and approaches from behavioral sciences, communication, social marketing, and health education (25).

The biggest problem with the current “Above the Influence” campaign is that the social influence has backfired (21, 26). Social influence can threaten people’s freedom to decide autonomously, to form their own opinions, to hold various attitudes (or none at all), and do what they feel free to do. When people feel that their freedom is threatened they experience reactance, a motivational state aimed at restoring the threatened freedom (21). This is why all public health campaigns are a pain to design, because all campaigns deal with telling people what to do, which as demonstrated by psychological reactance will have adverse effects on people. Trying to generate a social influence will not help here because congruent with reactance theory, a large literature shows that social influence is more successful when it does not threaten important freedoms (26, 27). Hence using Psychological Reactance Theory is going to help develop a successful campaign because the fundamentals of the theory lie in the effort to reduce reactance and improve compliance (28, 29).

In persuasion models, psychological reactance is presented as a mediator between communication and attitude/behavior (30). Direct restoration of freedom involves doing the forbidden act. In addition, freedom may be restored indirectly by increasing liking for threatened choice, derogating the source of threat, denying the existence of threat or by exercising a different freedom to gain feeling of control and choice (30).

Persuasive attempts of all sorts, including public health campaigns, often fail to produce the desired effect. In some cases, they even produce results directly at odds with their intents. The theory of psychological reactance provides one theoretical perspective through which these miscarriages might be understood. The theory contends that any persuasive message may arouse a motivation to reject the advocacy. That motivation is called reactance36. From this inception to the present, the theory may be called upon to explain resistance to long-term commitment. For reactant people, any lack of alternatives, high switching costs or long term contracts represents a threat to their freedom.

Proposed campaign; CHOICE

I would like to propose an Anti-drug campaign called the ‘Choice’ campaign. The target population of this campaign will be similar to that of “Above the Influence”, the adolescent youth of America. However, the essence of the ‘Choice’ campaign will be derived from the Reactance Theory. The campaign will be focused on minimizing any chances of reactance from the target population. At the same time, the campaign will attempt to plug all the loopholes of the “Above the Influence” campaign.

‘Choice’ will be a positive campaign which will be contrary to the current anti-drug movement.

The most important aspect of this campaign will be that it will not tell anyone what to do. The ad campaign will try and imbibe the spirit and the motivation in an individual to stay sober i.e., not to be under the influence of alcohol or drugs.

‘Choice’ will be a dual campaign i.e., it will feature two different kinds of advertisements and media campaigns; Choice–A & Choice–B.

Choice-A will on real life stories. They will not focus on any kind of research or models or numbers. The ad-campaign will have relatives of people who have either lost someone to alcohol or drug abuse or people who have sobered up themselves. The people on screen will not talk about how ‘everyone should stop drinking alcohol or doing drugs’, because it will induce reactance. These advertisements will focus on the lives of these people; they will talk about how they lost someone to drug / alcohol abuse or how one of their relative came out of it. Former drug/alcohol addicts will come on air to talk about their own stories. This approach is going to help score a lot of points because adolescents are going to be able to relate to the victims and survivors of alcohol / drug abuse.

Commercials – This part of the campaign will feature four commercials, which will try and add the perfect blend of celebrities and ‘the common man’. The first scene will have relatives, manager and colleagues of George Best [a Northern Irish professional soccer player, best known for his years with Manchester United. He was a winger whose game combined pace, acceleration, balance, two-footedness, goal scoring and the ability to beat defenders. He was one of the first celebrity footballers, but his extravagant lifestyle led to problems with alcoholism which curtailed his playing career and eventually led to his death in November 2005 at the age of 59. His cause of death was multiple organ failure brought on by a kidney infection, a side effect of the immuno-suppressive drugs he was required to take after a liver transplant. (31)] His colleagues will talk about how great a player he was and talk about the great times they had. Mid-way into the scene they will talk about George Best becoming the best player, comparing him to the likes of Pele, if he hadn’t been a slave of his alcoholism. This will be said with the truest of emotions, because Best was actually that good.

The second commercial will showcase the families, friends and coaches of a group of high school and college athletes who lost out on glory because they gave into their temptations. This commercial will again begin with short interviews of the important people in the lives of those players. Talking about the moments they cherished with them and then how they felt during the downfall of those players. This is also include some of the success stories of people who were under heavy and moderate influence of alcohol and drugs and how they fought their temptations and emerged victorious on the other side.

The third and the forth commercials will be based on common people; the boy next door, the girl next door or any person who an adolescent child will be able to relate to. Similar to the previous commercials, there will be stories of victories and losses, but all the stories will be captured in such a way that they reflect true and genuine emotion.

True and genuine emotion will help garner the trust of anyone who watches the commercials.

Choice-B will be a ‘happy campaign’. Advertisements in this part of the campaign will be positive, bright and in high spirits. These advertisements will be focused on showing the positives of being sober, without actually ever mentioning the harmful effect of alcohol or drug abuse. This campaign is going to focus on commercials which project a very happy and bright picture of life.

The commercial for this campaign will be more or less on the lines of the Pepsi commercial which featured during the Super Bowl 2009. The one with Bob Dylan’s forever young. The commercial will compare two ages; around forty years apart, it shows happy people, children hugging their fathers/mothers (who have returned from Vietnam and Iraq respectively), people dancing to roll and roll and to the tunes of house music in a club respectively, and comparing various other things from two different generations. The only common thing between the two generations will be happiness and the soberness (not under the influence of alcohol or drugs). The foundation of this commercial will be derived from the psychological reactance theory (21) and hence, there will be no mention of what the viewer of this commercial should do. But the commercial sure will indirectly link happiness with soberness.

Another part of the “Choice” campaign would be to completely upgrade and revamp the website. The website (abovetheinfluence.com) will be changed to ‘www.yourchoice.com’. The website will air the commercials and give stories in greater detail of all the characters spoken about in the “Choice-A” commercials. The website will give out information about drugs, but only the amount of information which is needed. The website won’t be about facts or research or number of people under the influence, it won’t say how dangerous being under the influence is, it won’t talk about the population, but it will talk about ‘one child who died last week’, it will talk about the sorrow and grief of his parents, his relatives and everyone. This the website will be converted into an online portal where visitors will be able to relate to the things mentioned and they will react to it in a positive way because they are not striped of their freedom to decide.

Choice – Tackling what failed

Choice, the campaign will try and plug in the loop-holes that the current campaign has. Choice, uses three things; motivation, logic and positivity to try and influence the viewers to stop using drugs and drinking alcohol. In contrast to the current campaign that uses information and the portrayal of drug and alcohol use as something that is terribly bad. Choice will acknowledge the fact that so many teenagers indulge in drugs and alcohol abuse because they “increase or decrease the release and the synthesis of endogenous opioid peptides -- endorphins released during excitement, pain and orgasm -- in distinct brain regions important for drug addiction”. The campaign will be such that teens will be able to relate to it and they will be motivated to stop the abuse. The focus of the campaign would be to help teens understand that, drug and alcohol abuse might feel good and even great right now, but it might be more than harmful “we (the teens)” can anticipate in the long run. And since this will come from people they look up to and respect they will be motivated to make a life-style change.

Conclusion

Alcohol and Drug abuse is a major problem in the United States, as shown in this paper, and it needs to be looked in a much more efficient and scientific manner. The ‘Choice’ campaign has everything that is missing in the current anti-drug campaigns going on in the United States. “Choice” tries to get into the psyche of the adolescent mind and manipulate it into generating the desired behavior without generating any reactance.

References –

1. Journal

Kelder SH, Maibach E, Worden J, et al. Planning and initiation of the ONDCP National Youth Anti-Drug Media Campaign. J Public Health Manag Pract. 2000;6: 14–26.

2. Report of Other Document

Office of National Drug Control Policy. National Youth Anti-Drug Media Campaign. Available at: http://www.mediacampaign.org. Accessed December 28, 2005.

3. Report or other Document

Office of National Drug Control Policy. National Youth Anti-Drug Media Campaign: campaign overview. Available at: http://www.mediacampaign.org/newsroom/ factsheets/overview.html. Accessed December 28, 2005.

4. Report or other Document

Office of National Drug Control Policy. National Youth Anti-Drug Media Campaign: marijuana initiative. Available at: http://www.mediacampaign.org/marijuana/marijuanainitiative.html. Accessed December 28, 2005.

5. Hansen W.B., Graham J.W. (1991). Preventing alcohol, marijuana, and cigarette use among adolescents: peer pressure resistance training versus establishing conservative norms. Preventive Medicine, (20), 414-430.

6. Website,

www.Abovetheinfluence.com

7. Report or Other Document

Amentano, Paul: "Must Not See TV: Stoners in the Mist", page 18. High Times, September 2008

8. Report or Other Document

National Institute on Drug Abuse/University of Michigan, 2009 Monitoring the Future Study Drug Data Tables, December 2009

9. Book Chapter

Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Sons. Individual health behavior theories (Ch. 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.

10. Book Chapter

Dillard J.P. & Shen L. (2005). On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 72 (2), 144-168.

11. Report or Other Document

United States Government Accountability Office. Contractor’s National Evaluation Did Not Find That the Youth Anti-Drug Media Campaign Was Effective in Reducing Youth Drug Use. Washington, DC:GAO 06-818, 2006.

12. Houston A. Marijuana Policy Project. “Above the Influence”of Wasteful Spending. District of Columbia: Marijuana Policy Project. http://www.mpp.org/library/above-the-influence-of-1.html

13. Report of other document

(http://www.colorado.edu/communication/metadiscourses/Papers/App_Papers/Jean.htm)

14. Book

Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Sons. Individual health behavior theories (Ch. 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp. 35-49.

15. Report

Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10(Supplement A): 19-30.

16. Book Chapter

Essentials of Health Behaviour. Social and behavioural Theory in Public Health.

17. Website

http://www.abovetheinfluence.com/the-ads/default.aspx?path=nav

18. Website

http://www.youtube.com/watch?v=nl5gBJGnaXs

19. Report

http://www.uk.sagepub.com/upmdata/19262_Chapter_5___Mapping_the_Internal_and_External_Environments.pdf

20. Website

http://www.waytoomany.com/forum/viewtopic.php?f=45&t=54689

21. Journal Article

Brehm J.W. (1966). A theory of Psychological Reactance. Academic Press, NY.

22. Website

http://www.youtube.com/watch?v=wd7hCDACkW8

23. Website

www.abovetheinfluence.com/

24. Report

http://cancer.gov/pinkbook

25. Report

http://www.cdc.gov/communication/cdcynergy.htm)

26. Book

Brehm J.W. & Brehm S.S. (1981). Psychological Reactance. Wiley and Sons, NY.

27. Book

Clee MA. & Wicklund R.A. (1980). Consumer behaviour and psychological reactance. Journal of Consumer Research. 6 (March), 389-405.

28. Journal Article

Brehm, J. W., &Cole, A. (1966). Effect of a favor which reduces freedom. Journal of Personality and Social Psychology, 3, 420–426.

29. Journal Article

Brehm, J. W., & Mann, M. (1975). Effect of importance of freedom and attraction to group members on influence produced by group pressure. Journal of Personality and Social Psychology, 31, 816–824.

30. Journal Article

Dillard J.P. & Shen L. (2005). On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs. 72 (2), 144-168

31. Website http://en.wikipedia.org/wiki/George_Best

Website http://www.upi.com/Health_News/2009/03/20/Alcohol-releases-feel-good-endorphins/UPI-89031237564899/#ixzz1LVAqEaHF