Monday, December 13, 2010

Drunk with Illusions of Sobriety: Failures of Past and Current Binge Drinking Campaigns – Adam Mathias

Over the last few decades, consequences regarding the overuse of alcohol have been a well-documented concern within the United States, as well as most developed nations. On February 5, 2004, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) set a clear definition for binge drinking. “A ‘binge’ is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above. For the typical adult, this corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours” (1).
Furthermore, excessive alcohol intake was shown to be the third leading lifestyle-related cause of death in the United States, behind only tobacco and poor diet/physical inactivity (2). Approximately 79,000 deaths attributable to excessive alcohol use occur each year in the United States (3). About 75% of the alcohol consumed by adults in the United States is in the form of binge drinks (4). In 2005, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that about 10.8 million persons ages 12-20 (28.2% of this age group) reported drinking alcohol in the past month (5).

Binge drinking is a major concern in public health due to its association with many health risks, including alcohol poisoning, liver disease, neurological damage, fetal alcohol syndrome, cardiovascular disease, as well as unintentional injuries (most notably car accidents) (6-8). As a result, a variety of binge drinking preventions have been established over the years. But a great deal of these interventions have either not been effective whatsoever, or have been minimally effective in achieving their overall goal of decreasing binge drinking.

First and foremost, most of the binge drinking prevention programs have focused their efforts exclusively on college students, and have basically ignored the additional circumstances in which binge drinking occurs as well as the repercussions of ignoring those who are overlooked. Second, preventions have done an inadequate job accounting for the real perceptions of attitudes and norms of its target audience, leading to a continuation of old behaviors. Finally, many interventions have completely disregarded or have given little concern to the theory of psychological reactants, in which individuals inherently want to do the opposite of what they are told.

Narrow Frame:

One binge-drinking statistic, which stood out from the rest, was that 70% of binge drinkers are over the age 25. This statistic highlights the fact that binge drinking is not limited to only high school or college student use, but that this issue has a high prevalence in the working adult population (9). This statistic contradicts what the majority of binge drinking prevention programs portray to the public.

Most binge-drinking campaigns target college kids, as they are thought to be the largest abuser of alcohol, but also focus much of their attention on confronting the high school populations. In 2005, approximately one in eight youths (ages 12-17) reported that they were participating in drug, tobacco, or alcohol prevention programs outside of school in the past year (5). In 2005, 59.8% of youths (ages 12-17) reported that they had talked at least once in the past year with at least one of their parents about the dangers of drug, tobacco, or alcohol use (5). Almost 80% of youths (ages 12-17) enrolled in school in 2005, said that they had seen or heard drug or alcohol prevention messages at school within the past year (5). It is easy to see that a great deal of resources go to shaping the children and young adults, the future of our country—but that is only 30% of the problem.

Furthermore, males are disproportionally addressed in binge drinking campaigns despite the fact that they have fairly similar rates of binge drinking as that of females. SAMHSA showed that there is almost an even distribution between males and females ages 12-20 who reported current alcohol use (28.9% vs. 27.5%), binge drinking (21.3% vs. 16.1%), and heavy drinking (7.6% vs. 4.3%) (5). Campaigns and ads generally target males, and even more so the young adult male population, depicted as the stereotypical binge drinkers. Potentially, due to the complexity of creating a viable solution, binge-drinking campaigns centered on the 25 and over populations are not overly prevalent, and yet this population comprises the vast majority of the problem.

Moreover, most binge-drinking preventions fail to take into account social and other environmental factors, such as educational attainment, religion, culture, or disparities. Certain campaigns, i.e. ones on college campuses, may cater their interventions towards certain age groups and educational attainment, but they pay little attention to socioeconomic status, race, religion, etc. By not knowing the audience, the prevention will be that much more ineffective—as effective persuasion utilizes principles that are completely dependent on certain characteristics, values, and various other social factors specific to that audience. Generally, these include: the principle of reciprocity, commitment, modeling, and liking.

Ineffective Health Belief Model:

Although the health belief model is ideal for education by bringing about pertinent information about a behavior in a simple and straightforward way (as illustrated in prevention programs for SARS, the recent bid influenza), it does not do a good job at predicting complex behavior. Along those lines, it is very precise at predicting simple decision-making processes, such as screening for STDs or receiving immunizations. Most notably, is it a poor predictor of behavior involving the constant need for decision making (10).

The Health Belief Model is an individual level model that assumes that people are first and foremost rational, and that they will consequently make rational decisions. This model is also based on the idea that people’s behavior is completely planned. These assumptions are wrong, as people are predictably irrational, and consequently, behavior is unplanned. Regardless, in this model the benefits of doing a certain behavior are determined by perceived susceptibility as well as the severity of disease or condition. On the other hand, the barriers to doing the behavior or action most generally include cost, discomfort, and/or inconvenience. The Health Belief Model assumes that individuals will first determine their relative susceptibility and severity, rationally weigh out the perceived benefits and costs, and then eventually decide to take or not take action (10).

But, it just so happens, that binge drinking does not involve a simple decision-making process. Information campaigns focusing on negative consequences are unlikely to have much impact on college students' alcohol consumption (11). Simply stated, many people inherently like risky behavior. Research has shown that college students involved in high-risk binge drinking already know that overuse of alcohol can potentially lead to serious injury and death (11). They also know from their own experience, however, that dismal, and potentially deadly, consequences are fairly rare events (11).

For example, in essence most Public Service Announcements (PSAs), such as that of the “Alcohol, know your limits” campaign, portray a young adult male and the consequences of binge drinking (12). These announcements portray binge drinkers in a very poor way, as a “scare tactic,” in hopes that the audience will determine their susceptibility and then the severe potential consequences associated with binge drinking, rationally weigh out the perceived benefits and costs of the actions, and then eventually decide that it’s not worthwhile to binge drink. But most individuals viewing this PSA would think that the effects illustrated are exaggerated, and that if they binge drink that will not be how they will respond. Furthermore, research has shown that serious injuries or death related to drinking are likely to be attributed to an error in that one individual's own specific actions, rather than to attribute the dire results as predictable consequences of excessive alcohol consumption (13).

Lack of Know-How Regarding Theory of Psychological Reactants:

Almost universally, no individual likes being told what do to. And yet, the phenomenon of a person reacting to a loss of freedom, especially when told to do something, is a common occurrence in society. Psychological reactance theory explains how people have an emotional reaction when their freedoms that are threatened (14). If individuals perceive they are being manipulated or are trying to be coerced (especially by an authoritative figure or group), they will often do the opposite of the suggested activity or behavior. This is done in order to maintain control and therefore preserve their freedom (15).

Public health interventions should try to minimize the use of this theory but it is almost impossible to create an effective intervention that is entirely non-authoritative and/or non-controlling. Even though that there is almost a certainty that psychological reactants will be evoked, does not mean that binge-drinking preventions should dismiss the theory entirely.

Improved Intervention:

A major detail that is distorted by many binge-drinking prevention campaigns is the fact that the target population is strongly influenced by the attitudes and behaviors of their peers. This basically describes the Theory of Social Norms (16). Regardless of whether that behavior is risky or not, people in the target population will continue to engage in the behavior as long as they believe that the behavior is typical among their peers.

Perkins and Berkowitz have conducted thorough research on the patterns of various misperceptions held by college students regarding the social norms of alcohol use among their peers. They found that students typically felt that the norms for both the frequency and the quantity of drinking among their peers are higher than they truly were. Additionally, they concluded that students generally believed that their peers were more permissive in their personal attitudes about substance use than was actually the case (17). Moreover, in research conducted in the Core Institute Survey on Alcohol and Drugs, it was found that at every one of the 100 colleges and universities in the study, most students perceived much more frequent use of alcohol among their peers than actually occurred at their school. This pattern was the result at each particular institution, regardless of real frequency of use. They concluded that exaggerated misperceptions of alcohol norms are commonly entrenched at schools across the country, regardless of region, size, and whether it was public or private (18). Furthermore, Perkins and Berkowitz feel that correcting such misperceptions may help reduce heavy drinking and related harm (17). It is extremely necessary that current preventions acknowledge and adapt their education program around the fact that most of the norms they teach are inaccurate. There is a great need to re-standardize norms used in binge-drinking interventions to stress that peers drink less than an individual would think and that drinking a large quantity of alcohol is less accepted than that individual would think.

As many preventions employ the “scare tactic” through the Health Belief Model in order to curb binge-drinking, a great deal of reactants is evoked. In order to minimize reactants in the target population, need to first assess and measure reactant proneness by a sample of the population. In an ideal world, an intervention program would be able to hide the specific source of the message to minimize reactants, and ultimately increase utilization of the desired behavior or action. The easiest method of hiding the source of the message is to facilitate learning through peer-educators.

Given the literature on the importance of peer influences in college student drinking, it is possible that motivational-and social-norms based interventions delivered by peers would be particularly effective. Research pertaining to role theory suggests students will learn more effectively from their peers than from individuals who are older and have different ‘generational values” (19).

A good example of successful peer-based health educators is the organization, founded in Massachusetts, called Students Against Drunk Driving (SADD), also referred to as Students Against Destructive Decisions. SADD is an alcohol prevention program that primarily targets middle school and high school age adolescents, and employs the philosophy “that young people, empowered to help each other, are the most effective force in prevention.” (20) This program aims to directly change the notions of peer alcohol use. Research supports the use of programs, such as SADD, stating that the “most effective programs utilize multiple years of behavioral health education, community-wide involvement and mass media complementing the school-based peer-led program.” (20)

Advertising theory can a very useful tool to motivate the targeted audience to act a certain way or elicit a certain behavior of. A campaign utilizing advertising theory will package the target audience’s deepest aspirations with the behavior change that is desired. The behavior change becomes reality after the company, or in this case campaign, promises that the target audience can fulfill those ambition by employing the behavior. According to Siegel, ultimately, the bigger the promise is, the more influential the advertisement will be in altering a desired behavior. But to work and actually be effective, the promise should be supported with effective imagery and factual information (21). Using advertising theory, instead of the health belief model, will allow the preventions to abandon the exploitation of “scare tactics.” In the end, it should produce more compelling and persuasive messages of behavior change, if the designers of the preventions properly research and assess the audience’s core values, and then successfully connect those core values with the desired behaviors.

A few years ago, public health practitioners were able to re-brand smoking, as illustrated by the “TRUTH” campaign. Smoking was re-branded as a product and market that was controlled and manipulated by “Big Tobacco.” Interestingly, there was a documented decrease of prevalence in smoking among youths in Florida because youths did not want to be manipulated (22). The “BOLD” campaign should focus on re-branding a healthy lifestyle, one that is free from the ill effects of the overuse of alcohol.

By taking back control of their freedom from a common enemy, in this case “Big Alcohol,” psychological reactants will be minimized. In collaboration with high schools, universities, and various other community organizations, this “BOLD” campaign can promote a healthy lifestyle for all age groups, races, religions, through advertising and mass media—parallel to that of the “TRUTH” campaign. The campaign would, of course, involve community wide-organizations. This whole new network of individuals, along with other peer-educators, can work together to empower one other to address binge-drinking in a proactive and realistic manner.

In addition to unifying against “Big Alcohol,” some of the issues that can be addressed are the benefits of reducing alcohol intake. These could include the money saved by not purchasing alcohol that could be used for other purposes including taking vacations, a new car, a new television, a new bicycle, etc., or even the weight loss possibilities due to alcohol’s high caloric values.


In an economically perilous time, it would be ideal to harness our time, money, and resources in an effective manner. Obviously binge drinking is a great public health concern, but as should be the premise of any public health prevention, research, assessment, planning, and evaluation projects that are more suitably conducted will be more successful to combat this widespread and multifaceted prevalence problem. Alternative strategies may be needed to battle the excessive and misuse of alcohol in the United States. Preventions should utilize group level models in tandem with individual tools of persuasion to successfully change behavior. The way that campaigns can affect behavior is often complex. If these complexities are not considered in the design and evaluation of interventions, many of the goals of the campaign will go unheeded. Unfortunately this has been seen by many of the prior and existing prevention programs utilized in the fight against binge drinking.

(1) National Institute of Alcohol Abuse and Alcoholism. NIAAA council approves definition of binge drinking. NIAAA Newsletter 2004; No. 3, p. 3.
(2) Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291(10):1238–1245.
(3) Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impact (ARDI). Atlanta, GA: CDC.
(4) Office of Juvenile Justice and Delinquency Prevention. Drinking in America: Myths, Realities, and Prevention Policy. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 2005.
(5) Office of Applied Studies. Results from the 2005 National Survey on Drug Use and Health: National Findings. SAMHSA, U.S. Department of Health and Human Services, 2004.
(6) Smith GS, Branas CC, Miller TR. Fatal nontraffic injuries involving alcohol: a metaanalysis. Ann of Emer Med 1999;33(6):659–668.
(7) Rehm J, Gmel G, Sepos CT, Trevisan M. Alcohol-related morbidity and mortality. Alcohol Research and Health 2003;27(1)39–51.
(8) Corrao G, Bagnardi V, Zambon A, La Vecchia C. A meta-analysis of alcohol consumption and the risk of 15 diseases. Prev Med 2004;38:613–619.
(9) Naimi TS, Brewer RD, Mokdad A, Clark D, Serdula MK, Marks JS. Binge drinking among US adults. JAMA 2003;289(1):70–75.
(10) Tversky, A, Kahneman, D. The Framing of Decisions and the Psychology of Choice. Science 211: 453-458, 1981.
(11) Wechsler, H., Dowdall, G.W., Maenner, G., Gledhill-Hoyt, J. and Lee, H. Changes in binge drinking and related problems among American college students between 1993 and 1997: Results of the Harvard School of Public Health College Alcohol Study. J. Amer. Coll. Hlth., 47: 57-68, 1998.
(12) Alcohol Know your Limits – Binge Drinking Boy. June 16 2008. Online video clip. YouTube.
(13) Lerner, J.J. The Belief in a Just World: A Fundamental Delusion, New York: Plenum Press, 1980.
(14) Clee MA , Wicklund RA. Consumer Behavior and Psychological Reactance. Journal of Consumer Research, 6:389-405, 1980.(15) Miller R. Mere Exposure, Psychological Reactance and Attitude Change. The Public Opinion Quarterly, 40:229-233, 1976.
(16) Bandura, A. Social Learning Theory. New York: General Learning Press, 1977.
(17) Perkins, H.W. and Berkowitz, A.D. Perceiving the community norms of alcohol use among students: Some research implications for campus alcohol education programming. Int. J. Addict., 21: 961-976, 1986.
(18) Perkins, H.W., Meilman, P.W., Leichliter, J.S., Cashin, J.S. and Presley, C.A. Misperceptions of the norms for the frequency of alcohol and other drug use on college campuses. J. Amer. Coll. Hlth., 47: 253-258, 1999.
(19) De Volder ML, De Grave WS, Gijselaers WH. Peer teaching: Academic achievement of teacher-led versus student-led discussion groups. Higher Educ., 1985;14:643–650.
(20) Students Against Destructive Decisions. Value of SADD. Marlborough,Mass: SADD.
(21)Siegel, M. and Lotenberg, L.D. Marketing public health: Strategies to promote social change. 2nd Ed. Sadbury, MA: Jones and Bartlett, 2007.
(22) Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control. 2001; 10:3 – 5.

Labels: ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home