Prevention of teenage smoking through negative information giving

Some German research which looked at whether delivering negative information to young people about the effects of smoking has a preventative effect caught my eye.

In their abstract the authors conclude:

Although the clinic intervention generated a significant immediate reaction, there were no significant preventive effects at follow-up. These results are in line with previous research and add further evidence for the ineffectiveness of emotionally arousing negative information giving in smoking prevention with adolescents.

I’d be interested in whether this suggests that when NICE come to review their guidance on preventing the uptake of smoking by children and young people they will need to change their view that negative information should be part of smoking prevention information and campaigns for young people.

It has to be said that the German research contrasts with the findings of a review of health messages on tobacco products which found:

The evidence also indicates that comprehensive warnings are effective among youth and may help to prevent smoking initiation. Pictorial health warnings that elicit strong emotional reactions are significantly more effective.

The Cochrane review of mass media interventions for young people has some interesting observations on what makes for a successful campaign.  The reviewers say:

Overall, effective campaigns lasted longer with a minimum of three consecutive years, and were also more intense than less successful ones for both school based lessons (minimum eight lessons per grade) and media spots (minimum 4 weeks’ duration across multiple media channels with between 167 and 350 TV and radio spots). The timing and type of broadcast made a difference to their success, with older youths in one study preferring radio to television. Implementation of combined school based curriculum/components (i.e. school posters) and the use of repetitive media messages delivered via multiple channels (i.e. newspapers, radio, television) over a minimum period of three years contributed to successful campaigns. Changes in attitudes, knowledge or intention to smoke did not generally seem to affect the long-term success of the campaigns.

Meanwhile the recent update to the Cochrane review of school based prevention of smoking suggests that schools should combine social competence and social influences interventions.

Talk to the hand, cause the face ain’t listening

If the evidence for youth focused mass media anti-drug adverts isn’t great what about focusing on parents?

I can’t say that I know whether there’s any more evidence for this approach, but it is certainly a tactic that those with budgets in this area have and are trying.

Today I came across the ‘Talk, they Hear You’ campaign that the Substance Abuse and Mental Health Services Administration in the US have put together to try to persuade parents that their influence on the risks their children take with alcohol can start earlier and go on longer than they might imagine.

As you can see the message is quite positive, and will be reinforced with online tools for practising the ‘awkward’ conversations and tricky issues that might be thrown up by an issue like alcohol.

It reminded me of the Why Let Drink Decide approach that briefly ran at the end of the last government where the message was a little darker, with pre-teens reminding us just how soon their innocence could be lost.

Can mass media campaigns prevent young people from using drugs?

The EMCDDA have reviewed the evidence for media campaigns aimed at preventing drug use by young people.  They note that one in three affiliated countries say they either don’t run these campaigns or have significantly reduced funding to them.

FRANK meowWe know that this includes the UK government which has cut spending on advertising the FRANK service year on year.  I think it is clear that the content of the last set of adverts that FRANK weren’t trying to effect young people’s behaviour, rather the aim was to drive traffic to the website, helpline and other services provided by the government.  Whether that’ll be true of the next set we’ll wait to see – I’m told there will be a focus on novel psychoactive substances over the summer period.

We have recently looked at other youth focused public health campaigns that Public Health England have inherited which aim to increase the positive conversations about health between peers and between parents and their children.


The conclusion the EMCDDA draw suggests that governments may be correct in being cautious in supporting this form of preventative action over other interventions given the current evidence.

They say:

The pooled analysis of studies found that media campaigns had no effect on reduction of use and a weak effect on intention to use illicit substances. Reports of possible unwanted effects in terms of young people declaring that after having watched a media campaign they were willing to try drugs raises concern. This is particularly relevant for prevention interventions, which are provided without a demand from the target population. Campaigns might affect individuals differently, depending on their level of awareness. However, being informed might not have a direct effect on behavioural change, while perception of norms (the perception that everybody is using drugs) may have an impact.

As a result they recommend that if campaigns are run they are only done so “in the context of rigorous, well-designed and well-powered evaluation studies.”

YouTube and drug videos

YouTube video Brandweer NederweertThis paper, by Paul Manning from the University of Winchester, has some really interesting analysis of the sorts of films being uploaded to YouTube about drugs, the substances being discussed, and the intentions of the film makers.

The paper suggests that for every official drugs education video there are a further 3 videos about drugs on YouTube.  But there is considerable difference in the number of videos made about different drugs and the number of times they get watched.   Continue reading

More on public health messaging

frank - cokeWe’ve seen that the Department of Health have decided to stop paying into the advertising budget for FRANK TV ads and posters, like the one to the right.

A recent conversation I had with someone in the DH suggested that one of the reasons for that was because they want their advertising spend to lead to a change of behaviour.

My view of FRANK adverts (both print and digital) is that their purpose is to persuade young people to use other parts of the service (website, helpline etc.) rather than change behaviour per se.

That may be a good thing as the recent article on the BBC’s website about FRANK pointed out there isn’t much evidence for media campaigns changing people’s behaviour when it comes to drugs.  Indeed this helpful summary of the evidence on Drug and Alcohol Findings suggests that US attempts “may have promoted more pro-cannabis attitudes and beliefs”.

Nevertheless, posters remain a core activity of a lot of public health campaigns.  So, if you were going to try to develop a campaign that does lead to behaviour change what might you do?

Continue reading

Just cause you think you’re doing good…

Drinkaware Posters

Visiting the City Health 2012 conference yesterday I came across a piece of research (above) that brought me up short.

Researchers from London South Bank University and the Institute of Psychiatry at Kings College have been looking at the effects of Drinkaware‘s Why let the Good Times go Bad posters on drinking behaviour.

As you’ll see, from the example on the right, the posters contrast the difference between having a good time in a ‘responsible’ manner and having a night you’d rather forget.

The researchers built a simulated bar environment as well as carrying out the experiment in a student bar and observed whether seeing the posters (or not) makes a difference to behaviour.  The students were invited to take part in what was described as a Taste Preference Task:

This involved participants tasting a range of different beverages (e.g. beer, wine) and then rating each according to a number of features. Participants were not aware that the true objective of the study was to determine the total volume of alcohol consumed during the study.

What they report is that those who saw the posters were more likely to drink significantly more than those who hadn’t.

Understanding why the posters have the opposite effect than intended is a matter for some speculation – was it that a ‘responsible’ drinking message gives permission to drink, was it that the posters were poorly designed, was it that the messages were wrong?  What we do know is that this isn’t the first time that a public health message has had a boomerang effect – the exact opposite to the one that is intended.

And, while there is no doubt that this research has some limitations, the fact is they’ve replicated the results more than once and so emphasised to me that good intentions and a clever idea are not enough when it comes to a complex health intervention.

The other lesson to take is that testing your product, before going to scale, should be an essential part of any prevention initiative.

They’re under the bed…

There’s an excellent post about the use of vivid imagery and provoking fear through public health advertising over on the Brief Addiction Science Information Service blog.

As they say:

Using provocative and disturbing imagery as part of anti-drug advertisements might be unwarranted if it has not been demonstrated to be effective. More research needs to determine whether these kinds of advertisements are successful in preventing harmful drug use and promoting treatment-seeking behavior. Absent careful evaluation demonstrating the efficacy of prevention efforts, the potential for unintended consequences is great. Consequently, vigilance and careful evaluations are key components of effective interventions for addiction.

Does evidence support calls for an advertising ban on alcohol?

The Telegraph quote Sir Ian Gilmore’s views about alcohol advertising, he says:

“The evidence shows that when children are exposed to adverts they tend to drink at an earlier age, to drink more, and are more likely to end up developing a problem with alcohol in later life.”

To him and the large number of public health bodies that put their name to a submission to the Health Select Committee the answer is to ban alcohol advertising entirely.

There is a lot of evidence to suggest that Sir Ian is right about the impact of alcohol adverts on young people.

This recent piece of research, for example, looked at the difference marketing makes between the ages of 13 and 15 and found:

after controlling for confounding variables, involvement with alcohol marketing at baseline was predictive of both uptake of drinking and increased frequency of drinking. Awareness of marketing at baseline was also associated with an increased frequency of drinking at follow-up.

As Gerard Hastings points out in a fascinating presentation given to the EU’s Committee on National Alcohol Policy and Action in April this year this has been understood for some time [see right].

Whilst there are academic advocates for banning advertising the evidence doesn’t seem to be as strong as it could be.

There are, however, limitations to the research.  This review for the Department of Health from 2008 came to the conclusion:

Studies examining the effects of alcohol advertising on consumption do not support or counter a hypothesis for a causal relationship. This is mainly attributable to the considerable variation in the use of advertising bans across countries and methodological challenges. It should also be recognised that imposition of a ban may require an extended period of time, within which to affect consumption and even longer to have an effect on harms.

Evidence statement 11: There is some inconclusive evidence that suggests that advertising bans have a positive effect in reducing consumption. Differences in contextual factors are a likely explanation for these differences. It is methodologically challenging to control for all possible confounding factors.

Evidence statement 12: There is some evidence to suggest that bans have an additive effect when accompanied by other measures within a general environment of restrictive measures.

This review for Alcohol Concern Wales paper points to work by Professor Petra Meier (the person who did all the modelling for minimum unit pricing) which found evidence pointing in both ways, with one estimate seeing a reduction in consumption by 26.9% and another arguing that there could be an increase by 4.9%.  She ends up concluding:

To date, research has tended to rely on simplified models of marketing and has focused disproportionately on youth populations. The effects of cumulative exposure across multiple marketing channels, targeting of messages at certain population groups and indirect effects of advertising on consumption remain unclear.

Also of interest is this paper, from the Institute for Alcohol Studies, about the internet’s influence on adolescents attitudes to alcohol, which suggests that peer generated imagery and commentary about alcohol is much more significant than professionally produced advertising.  They say:

Participants also indicated that they were largely unaffected by alcohol advertising online, and while this seems unlikely given the persuasive and effective nature of advertising, only 12% of alcohol content online represented identifiable instances of marketing, so it would seem likely that effects transmitted through interacting with and absorbing alcohol media came mostly from sources that were not advertising.

Alcopops not that attractive to young people…

Taken from the minutes of recent EU committee on Alcohol which had a presentation on drivers in young people’s drinking habits analysing data from the recent European school survey:

The results indicated variation between countries in levels and trends of the consumption of ready-to-drink mixtures, with price being a factor. Under age drinkers try alcopops relatively “late”, cider commonly being the first beverage to be tried and spirits the last. Minimum age was found to have significant impact on the age when alcohol is first consumed. The most important determinant of the consumption of any alcoholic beverages was the influence of friends who also drink. The analysis did not find meaningful evidence within the drinking patterns of 15-16 year olds that alcopops would have any features different from alcoholic beverages in general. Across the product categories examined, the marketing strategies are similar, highly sophisticated, glamorous and appealing, with emphasis on social media and web sites.

Remember that this is EU data and that very few British schools took part, so it may be different in the UK.

Also of interest, from the same minutes, is a discussion that took place about alcohol advertising and young people:

Ellen Nolte presented preliminary findings from ongoing work by RAND Europe under the EU Health Programme. The study is the first in Europe to use on a larger scale audience demographics and data on advertisement placement to assess the exposure of young people to alcohol advertising through television and online media. Due to the prohibitive price of data acquisition the analysis is limited to three EU countries. The findings so far indicate that 10-15 year olds are disproportionately exposed to alcohol advertising on TV compared with viewers aged 16-24 years or with
adults above the age of 24 years.

And on that subject see Gerard Hasting’s presentation on the impact of alcohol marketing on young people’s drinking in which he reports:

After controlling for confounding variables significant associations emerged between awareness, appreciation and involvement with alcohol marketing at Stage 1 (aged 13) with drinking behaviour at Stage 2 (aged 15):
– earlier age of uptake of drinking
– amount consumed