Friday, December 10, 2010

Four Loko Banned: The Ironic Outcome of Public Health Measures to Reduce Consumption-Jasmine Vakhshoorzadeh

Mixing alcohol with either energy drinks or a different type of caffeinated beverage is not a new creation. In fact, the Journal of American College Health reported in June 2008 that about 26% of college students were mixing some type of caffeinated product and alcohol together (1). The more commonly preferred drinks include Red Bull with vodka, rum with coke, and, most recently, Four Loko.

Four Loko is a drink produced by Phusion Projects Incorporated targeted mainly at underage, college students. It derives its name from its four main ingredients: caffeine, guarine, taurine and wormwood, an active ingredient of absinthe (2) mixed with alcohol. The product, packaged in a convenient 23.5 ounce can and sold for $2.50, contains 156 milligrams of caffeine mixed with the equivalent amount of alcohol contained in four beers (3). Four Loko is offered in a variety of eight different flavors, making it an appealing choice to underage drinkers. By offering a wide selection of fruity flavors combined with vivid colors and graphics on the labels, Four Loko is targeting underage students.

Four Loko, commonly referred to as “blackout in a can” and “liquid cocaine”, has caused the hospitalization of 23 students in New Jersey and 9 students in Washington(4), consequently becoming a recent pressing health concern. Most of the students hospitalized were inexperienced drinkers between the ages of 17 and 19 (4). It has now become one of the most talked about products among college students nationwide.

The reason that Four Loko has been criticized more than some of the other caffeinated alcoholic beverages is that a low price for such a powerful drink is extremely tempting for young adults. It is by far their cheapest option to get drunk. Students “pre-game” by drinking only one or two cans and feel just as drunk as if drinking four to eight beers, depending on which Four Loko they buy. Buying the equivalent amount of beers is more costly, and similarly, consuming this quantity of beers is far more time consuming than just drinking one Four Loko. The students are getting their ‘bang for the buck.’

The mixed product is considered dangerous in the physiological effects it causes to the body. Caffeine, guarine, and taurine, all stimulants, mask the effects of alcohol (a depressant) and make students feel more sober than they actually are (1). This deceiving state has caused many students to continue drinking large quantities of alcohol without realizing how much they intake, leading many of them to consume excessive amounts of alcohol and, in many cases, hospitalizing them as a result of alcohol poisoning.

While the FDA continues to look into the safety of mixing high amounts of caffeine with alcohol, many institutions are concerned about student safety and have taken precautionary measures by sending out warning messages to their students. Universities, including Boston University, Harvard, Northeastern and Boston College, sent out mass emails to students warning them about the dangers of Four Loko (5). The controversy has also sparked some states to ban the sale of Four Loko in stores (6).

Unfortunately, these measures are not likely to produce the desired results of stopping underage students from consuming the products. The interventions rely too heavily on the outdated Health Belief Model, and are flawed in not accounting for important theories of social science, theories that would explain how students are most likely to respond to the messages and ban. Without consideration for psychological reactance and the principle of scarcity, this approach falls short of being an effective means of reducing the number of students drinking Four Loko.

Why Warning Messages Were Not Effective: Too Much Emphasis Put on the Health Belief Model

The hospitalization of over 30 students captured national attention. In response, the FDA alongside many universities issued warning to students about the dangers of consuming Four Loko. For example, Boston University sent an email to all its students, warning them about the dangers of Four Loko, and concluding with: “Boston University is concerned for your personal safety and we hope that you will use this information to make wise healthy choices!” (5).

Messages like these are based on the Health Belief Model (HBM). The HBM has been used as a basis for creating many public health interventions since the 1950s. According to the original theory, behavior is based on four factors: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers (8). The idea behind the model is that people, when provided with the correct information, will make a rational decision about their health based on these four factors. If one believes he is highly susceptible to a negative outcome, then an individual will make a rational, conscious choice to not engage in the behavior. If the individual thinks that the health problem is severe, he will not engage in the behavior. If the perceived barriers are low and perceived benefits are seen as high, the individual will chose to engage in healthy behaviors (8).

The warning messages sent out are based on these very ideas. The messages contain information about how dangerous it is to mix caffeine and alcohol matches with the idea of perceived severity and high risk. Susceptibility of students and perceived barriers are pointed out when the messages discusses all the hospitalizations that have occurred because of consuming the Four Loko, and the same will happen to anyone else who drinks it. Further, the messages affirm that students will gain no benefit from consuming the product, and that it is not safe, so don’t drink it. (5)

The warnings were sent out in hopes of providing students with information about the perceived severity of the product. With a high perceived severity, officials believed that students would make a rational decision to not drink Four Loko because they would realize how dangerous the product is. Many officials believed that using the principles behind the Health Belief Model (HBM) would result in a positive response. Even though these messages have good intentions to control the issue, they are not likely to be successful.

First, the intervention is not likely to be successful because many healthy people do not value health (9), which goes against the basic idea of the HBM. By conveying messages about health, we are not connecting with our target population. The students do not care about health, so perhaps the message will just be disregarded as unimportant. Students do not value health at the same level as the model perceives them to, and their core values are more geared towards their desire of obtaining control and freedom.

Second, a flaw of the intervention relying on the HBM is a lack of consideration for risk-taking among adolescents. Studies have shown that during the transition time between youth and adulthood, adolescents are more likely to engage in risk-taking and novelty seeking behaviors compared with adults (10). By providing information about how dangerous and risky consuming Four Loko is, we are introducing the idea of Four Loko as a risky and dangerous behavior, which consequently will increase the students’ desire to consume it. By telling them it’s risky and dangerous, we are fostering their desire to seek the product and by providing them with the source to rebel against. Even though they are well-aware of the potential negative outcomes from drinking it, engaging in this risky behavior gives them an adrenaline rush. Studies have found that there is a strong relationship between risk behavior and sensation seeking (11). One study showed an interesting result of many people taking certain risks because of the adrenaline rush that it gave them while engaging in the behavior (11). Further, this study also showed the negative risk behavior was higher among adolescents who were told not to do something by teachers and parents. Therefore, by introducing the idea of Four Loko as a risky behavior, we are attracting many adolescents towards the product. We are offering them a new way of obtaining that adrenaline rush. With this increased appeal and desire for the adrenaline rush associated with the drink, more students are likely to fulfill these needs by engaging in the risky drinking of Four Loko.

A third problem with using the HBM in this situation is the negative tone of the message. By using the fundamental concepts of severity and susceptibility, the messages are conveying a negative tone, which are likely to meet more resistance from the target population. By creating a negative association with the source delivering the message, the adolescents are likely to use that as a rejection cue, since they see the source as untrustworthy (12). Furthermore, the messages do not offer better alternatives. They do not discuss any benefits if an individual chooses not to drink Four Loko. The messages only focus on what an individual can avoid by not drinking it. We should offer better alternatives to the students if we are going to tell them to stop drinking Four Loko.

Another problem with basing messages off the HBM is the lack of consideration for social factors. Peer pressure among adolescents can lead them to engage in unhealthy behaviors (13). The messages do not provide information on how to avoid situations when one is present in a social setting. Further, many of the adolescents consuming the products are those in the transition stage, so they are trying to establish their own sense of identity and independence (10). If one refuses to engage in drinking the forbidden, risky product, then there might be social consequences for him. He might be seen as un-cool when he wants to be part of the popular crowd. These consequences can lead to diminished self-esteem if the adolescent is unable to establish his sense of identity and independence. Taking these types of social pressure situations is an important part to formulating intervention methods because they can predict human behavior more accurately and result in more successful interventions.

Overall, using messages that rely on rational decision-making based on the principles of the individual level HBM is not likely to succeed in lessening the consumption of Four Loko.

Lack of Consideration of Psychological Reactance

Once warning messages were sent to the public, many state governments felt that more rigorous measures were necessary to curb the problem. In an effort to decrease the number of adolescents consuming the dangerous drink, many states quickly enacted a ban on the sale of Four Loko (14). In an ideal world, perhaps this would have been a very effective way of deterring people away from consuming Four Loko. In reality however, implementation of a ban following warning messages are likely to cause an unintended increase consumption of the Four Loko due to reactance.

The theory of psychological reactance is important for understanding why student consumption of Four Loko is bound to increase after sending out warning messages and then implementing a ban. According to the theory, messages that are perceived to threaten one’s personal freedoms (for example, choosing whether or not to drink) intensify his motivational state of reactance (15). This stimulated emotional state drives individuals towards re-establishing his lost sense of freedom by doing the opposite of what they are told, known as the boomerang effect (16). Such reactions have been studied in previous campaigns aimed at reducing alcohol consumption among teenagers. These studies found that these types of health messages threaten an individual’s freedom and elicit reactance, resulting in rebellion, as described by the boomerang effect (17).

The current warning messages are inducing reactance by conveying the dangers and health risks of Four Loko. We are telling adolescents to NOT drink the product, and basically threatening their independence. To add to this, we are now implementing bans and completely removing the product from their hands. Essentially, we are taking away their freedom to choose if they want to drink it or not. We are threatening their core values of freedom and control. Studies in which there is a clear attempt to restrict or eliminate individuals’ freedoms suggest that reactance causes message rejection in the form of increased liking for the activity or choice that was threatened (18). Based on this evidence, we can extrapolate that as the ban becomes present in more states, students are likely to respond to this by rebelling against the law in an attempt to regain their freedom and control. Students will start to actually prefer drinking Four Loko.

A problem that public health officials must face while dealing with this topic is that reactance is particularly intensified among teenagers and young adults. The teenage years are important years in the development of a sense of self and individuality (10). As a result, such messages are likely to induce a negative response as the students attempt to distinguish their own identity by deciding on their own habits and behaviors and fulfilling their needs and values. Further, implementation of a ban that seems to target that population will elicit a stronger response from the adolescents who now need to regain their sense of control in order to feel content.

An additional flaw in the current intervention is the source of the message. Traditional dogmatic messages warning undergraduate students of the dangers of alcohol consumption are considered as a high threat to the students have been shown to increase the reactance of students, which then resulted in greater consumption of alcohol (19). These traditional methods use more authoritative figures as the source of the information. Students are more rebellious towards these authoritative figures. In the current intervention, we are using government and higher authorities to convey the message to the adolescents. These authorities are also responsible for taking away the product from them by implementing and enforcing the ban. So, by telling the adolescents to not drink Four Loko and taking away their freedom to do so, authorities are effectively encouraging the behavior. This type of behavior is described by the boomerang effect (17). Students will react by doing the opposite of what they are told. The students feel threatened and must regain freedom back over their lives in order to feel content and in control. This rebellion could also inadvertently lead to more serious problems such as binge drinking and alcoholism.

Risk perception is also a very key component of the psychological reactance theory. The messages that emphasize the risks of Four Loko, along with the ban that reiterates that the product is risky and dangerous, are bound to cause more appeal to the students. These students want to engage in risky behaviors that give them an adrenaline rush (11) and a sense of control. By highlighting the risks and telling adolescents not to drink Four Loko, we are actually providing a reason to the adolescents of why they should drink it.

The elimination of Four Loko amplifies the effects of reactance. The choice is completely taken away. Adolescents will now feel the need to regain control of themselves and their freedom. The ban will also threaten the freedom of students who never used the product before the ban. Those individuals now will also feel the need to respond to the authorities taking away their freedom and control. Students want to be in control of their own lives and make their own choices on what’s best for them.

Unfortunately then, as these products become more banned and shunned nationwide, students will likely be taking a more keen interest in consuming them.

Principle of Scarcity Not Considered

On the surface, implementing a ban may seem like the most effective intervention. After all, by removing the product from the shelves, it is made inaccessible to underage drinkers, right?

Unfortunately, this belief is far from the truth. After hearing the news that many stores would be banned from selling Four Loko, students rushed to purchase them in bulk amounts. Store owners in Washington DC commented on the spike in sales of Four Loko after students heard that the product would soon be pulled from the shelves (20). The states of Washington, Utah, Oklahoma, Michigan, New York, Delaware and Massachusetts have all recently banned stores from selling Four Loko. It would not be surprising if stores in all of these states experienced a spike in sales as the talks of a ban came to the forefront.

The reason behind why such a sudden outburst occurs can be explained using the principle of scarcity. The basic premise of the theory is that people value opportunities more when they are less available (21). This premise is supported by the idea that products that are more difficult to attain are considered more valuable, and limited availability of such an item makes it appear as a high quality item (21). Further, as a product (for example, Four Loko) becomes less accessible, the freedom to possess it is lost. People do not want to lose opportunities. Therefore, people will respond to this loss of freedom by wanting the product more. In addition, the recent time frame of the ban makes the items take on a higher value compared with items that have been prohibited throughout our lives (21). People would desire that product more strongly than they did before since the product would become associated with a higher value.

As more states implement a ban on selling Four Loko, the quantity of the product becomes limited. As the product becomes more inaccessible, it is likely that the appeal for Four Loko will increase among adolescents. The product would be considered a high quality, attractive product. Students will look for ways to drink it as it becomes scarcer, more valuable and more appealing to them. If they are able to obtain Four Loko, the adolescents will feel as though they have obtained something that others have not. While they may not necessarily reap direct benefits from buying and consuming the drink, people feel as though they are avoiding the negative consequences if they buy and consume it. This feeling will give them a sense of accomplishment and confidence for rebelling successfully.

The value that students assign to the product will further be amplified by the recentness of the ban. Because the product has not been banned their whole lives, students now feel as though their freedom has been taken away, and are forced to rebel to regain their freedom. As we take away students’ freedom to choose whether or not they want to consume the product, we are also encouraging the desire of prior non-drinkers to engage in drinking it. Students do not want their freedom of choice to be limited, so they naturally will behave to counter the ban and buy their freedom and control back by purchasing and drinking Four Loko. Therefore, not only are the bans encouraging students who drank it prior, but they are also creating a reason for non-drinkers to drink it.

The implications of this theory are important in considering whether implementing a ban will resolve the issue of students drinking energy drinks with alcohol, such as Four Loko. There is a reason why we have the expression that ‘we all want what we can’t have.’

A More Effective Approach:

Implementing a ban after sending out warning messages about Four Loko is a flawed strategy that is prone to backfire. These interventions lack adequate consideration of and attention to solid social science theories. Therefore, in my opinion, a more effective way to reduce consumption of Four Loko would be to stop focusing our attention on banning the products and instead focus on creating a nationwide social marketing campaign.

The campaign should be modeled after the Truth® campaign, an anti-tobacco campaign aimed at decreasing adolescent smoking. The Truth® Campaign was a successful social marketing campaign that used solid social science principles to appeal to the young children and effectively reduced the number of adolescent smokers (21,22). The campaign was based on core values of independence and rebellion, and was met with high success rates, as 90% of students between the ages of 12 and 17, approximately 25 million students, said that the ad was convincing, and 85%, or 24 million of those individuals said that the ads made them not want to smoke (24).

With such a high success rate in the tobacco industry, the Truth® campaign may also be equally valuable for us to use as a way to successfully tackle the issue of adolescent consumption of Four Loko. Our marketing campaign can be modeled on the Truth® Campaign’s use of advertising theory (22). The campaign will shift the focus of the source of messages to the companies themselves. The campaign will frame the issue differently and will use core values of control and independence as the underlying themes of the messages. It will avoid the flaws in the current intervention by incorporating group dynamics and psychological reactance, and will not use health as the main argument to convince adolescents to not drink Four Loko.

Avoiding Health, Severity, and Susceptibility as the Basis for the Intervention

First and foremost, our campaign will not be solely based on the Health Belief Model. The model is flawed in that it assumes people will take action if perceived severity and susceptibility are high (8). While educating the public about the truth is important, we will frame the issue much differently. We cannot assume that telling people that they are going to get alcohol poisoning if they drink the product. Health is not highly valued by most people (9). We need to offer an alternative, instead of just telling them how to avoid a consequence.

Therefore, it becomes crucial to use a different strategy in order to sell our argument. We will educate the public about the truth of the product, but will not use health as the focus of our argument. Instead of focusing on health as the core value, we will focus on the core values of independence and control. These values will create positive alliances between the messages and the adolescents receiving them.

The campaign will focus on education, but will exclude words such as risk of consumption and “you are susceptible, so don’t do it.” Adolescents are high sensation seekers, and many of them are looking to take risks (25). They want to look more mature among their peers, and they are more willing to take the risks to do so. We can use this to our advantage by encouraging them to take risks to stand up for themselves.

We will frame the issue as the companies taking advantage and controlling the students. By framing it in this manner, we spark negative feelings towards the companies. The companies will now look like the bad guys, and students will want to rebel against them rather than us.

In return for the adolescents rebelling against the companies, we can offer promises of happiness, strength, vigor and success. This would be a successful way on using advertising theory in our campaign, since these promises are all positive qualities that people tend to strive towards.

Psychological Reactance Used to Our Advantage

Implementing a ban causes increased reactance among the target population. Hence, if we do not use a ban and use other means of controlling the use (and abuse) of the product, we are less likely to create the desire to rebel against the law by buying the product. When students do not have access to something, it creates the desire for them to rebel. Therefore, if we avoid banning a product quickly, we can avoid the additional reactance that was created by the ban itself.

In our campaign, instead of ignoring psychological reactance, we can use it to our advantage for delivering the message. The campaign would be centered on the idea of reactance, but used in a different way than what has been done. We want to create positive behavioral changes. We can appeal to the students by portraying the truth about how Phusion Projects is trying to manipulate them. By framing the issue and the truth in this manner, the attention is shifted towards the companies. We introduce reactance among the adolescents, but now their response will be directed towards the companies trying to harm them and take away their freedom.

Our campaign should minimize the authoritative voice of the source by using students as our campaign leaders and advocates. The role of similarity increases compliance and decreases resistance (26). Fellow students are less threatened by each other, so we can minimize the dominance effect and make the leaders more similar to the target audience, which lessens reactance.

The campaign leaders would include positive messages towards the audience, such as what they used in the tobacco campaign: “you’re smart enough to make your own decisions!” (24) This strategy minimizes reactance of the students and creates positive associations with the campaign messages, as their fellow students are giving them positive encouragement. More, the students receiving the message are more likely to trust what their fellow classmates tell them compared with what an authority tells them (21).

The campaign will focus on the promise of happiness and strength by regaining freedom, control, and independence that the companies are trying to steal away. These values are closely related to psychological reactance, and we can use this to our advantage. In getting out the truth, the campaign would use advertising and marketing theory strategies by containing images and sound to support the idea of the large corporation taking advantage of students. Hopefully, this would create negative associations towards the company and, consequently, the product. For example, the message we would hope to send out would be that “by consuming Four Loko, you are letting the company control you. They are taking away your freedom! They are out to get you!”

We could further support our argument by emphasizing the colors, graphics and flavoring, and make the statement that such techniques were targeted specifically at the underage population. We would explain that by buying the product, the students are being fooled and manipulated by the companies. This strategy places strong negative associations with the company and product, but places only positive encouragement with the actual campaign itself. By including their core values and encouraging them to rebel in an attempt to reclaim those values, students will react towards the negative messages. We also will have created a brand for our campaign.

The students will be more likely to rebel against the big companies if we emphasize how these companies are trying to take away control and independence by selling their product. When students then buy the product, then they are being tricked and falling into the hands of these large corporations and losing control of themselves. This type of approach will diminish the desire of the students to buy the product in an attempt for self-fulfillment and maintaining their freedom and control. By doing so, we emphasize the corporations wanting to take control of the students, and provide the students with a tempting reason to rebel. We also are using large corporations as the authority figure and increase the desire to rebel against these big companies. This may contribute to an increased desire to react since we include the corporations, big authoritative figures, as the source. The encouragement of their fellow peers will make them feel more confident about doing so, which will also avoid the problem of social norms and peer pressure. We introduce a social norm by using peer leaders. We tell them that others are rebelling by not drinking. In essence, we can create a herd effect (27).

Therefore, we can use the idea of psychological reactance to our own advantage to decrease the appeal of Four Loko among adolescents.

Principle of Scarcity Avoided completely

Previous research has demonstrated that framing issues in terms of what people have to gain is not nearly as effective as couching them in terms of what will be lost (28). Stating explicitly and directly what will be lost by an action is often a much stronger motivator than what will be gained. Therefore, by banning the product, we effectively created an increased appeal towards Four Loko.

The way we can correct this is by retracting the ban. Once we lift the ban, the product becomes more available. The increased availability of the product will make it less attractive and valuable among students, since it becomes more common. When something becomes scarce, people anticipate the possible regret that may occur when they do not acquire it, which increases their desire for it. Furthermore, the desire is increased if one thinks that someone else might get it before he does and gain something that he didn’t. People are afraid of lost opportunities. If we don’t ban or limit the quantity of Four Loko, then we can limit the amount of competitiveness towards the product among the adolescents. We can avoid thoughts of lost opportunities, and instead offer them an opportunity to gain back their control.

Banning the product also creates more positive feelings towards it. People want it more if it’s banned, and studies have shown that they tend to enjoy it more if it is scarce (29). By revoking the ban, we are not inducing a strong desire among the students to want to purchase the product. We essentially can avoid making the product seem better than it actually is. And then, we can then focus our attention towards our campaign to educate the public.


The current interventions that attempt to reduce consumption of Four Loko and similar products among adolescents are not likely to be effective. They are flawed in their limited consideration for psychological reactance and scarcity, and rely too heavily on the ancient individual level Health Belief Model.

Public health interventions should incorporate branding and marketing strategies more often. These strategies have the potential to be very successful in promoting healthier habits and change. If we create a social marketing campaign, and base our campaign off of the Truth® anti-smoking campaign, we may be able to create a more effective intervention that produces more desirable results. Our campaign will be run by student leaders, and will use psychological reactance and the core values of freedom and independence as its foundation. We will shift the focus of our campaigns towards these large corporations and create negative associations between the corporations and the targeted population.

Adolescent abuse of Four Loko continues to be a significant problem. As stated by Chuck Schumer, a senator of NY, the consumption of Four Loko is “spreading like a plague across the country” (6). The outcry against the ban continues to grow, as students nationwide have created Facebook groups, twitter pages, and Youtube videos that support the drink. Videos on Youtube show Four Loko vigils that students are holding to say goodbye to their beloved drink (30). Public health organizations need to respond with a more effective intervention before the student population becomes too “Loco for Four Loko.”


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