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Science-Based Public Service Announcements

Changing behavior is difficult. It is also an increasing priority for health care. We have entered a period of history when lifestyle choices have a dominant impact on health and longevity. People are no longer dying young of incurable infectious diseases in significant numbers. Rather they are surviving long enough to die from their bad habits.

Further, health behaviors are having a huge impact on the overall cost of health care. So the motivation is greater than ever to impact public health by influencing behavior. Yet, we are not very good at doing this.

It’s not that we’re not trying – it’s simply that having a large influence on people’s day-to-day behavior is remarkably difficult. There is ongoing research looking at how to effectively change behavior at the individual and public level, but it is complex, often conflicting, and new techniques at best yield only marginal gains.

The default method for changing behavior has been education – explain to people what the risks are of certain behaviors and the benefits of changing. I tell patients every day, for example, the risks of smoking and why they should quit. Of course, they all already mostly  know everything I tell them. I try to use the latest techniques, like motivational interviewing and social norming. I ask them what their health goals are, and explain that quitting smoking will help them achieve their goals, and I have many other patients who can do it.

But – the effectiveness of individual counseling is extremely low. A recent review concludes:

Physician brief counseling and trained health professionals’ intensive counseling (individual, group, proactive telephone) are effective with abstinence rates between 2.1% and 17.4%. Only practical counseling and motivational interview were found effective intensive interventions. The clinical effect of smoking cessation counseling is low and long term cessation rates uncertain.

Obviously individual counseling alone is not going to be enough, even with intense innovative techniques. Public health interventions are also needed. There are two general types of public health interventions, mass public education (such as public service announcements, PSAs), and regulation that is designed to make it more difficult to engage in unhealthy behavior.

The latter does seem to have an effect. Taxes on cigarettes, for example, are effective (although tobacco companies try to offset taxes with lower prices). Banning smoking in certain public locations is also effective. Attention is now turning to similar regulations to reduce obesity, such as the infamous proposed ban on large drinks in New York City. There are regulations on tobacco advertising, and on packaging.

The overall goal of such regulation is to minimize enticements for unhealthy behavior, and to make the behavior as inconvenient as possible.

What about PSAs? How effective is it to have commercials of the famous “this is your brain on drugs” type? Recent research has been looking at how to fashion PSAs for maximal impact. One recent study looked at 71 subjects exposed to ads with either strong content or weak content, flashy editing or plain editing.

Encouragingly, they found that having a strong message was the more important variable. If the PSA had a weak message then it did not matter if the editing was boring or flashy. If the PSA had a strong argument then it was effective even with plain editing, but more so with flashy editing. The study used fMRI to image subjects watching the PSA and found that strong messages engaged the decision-making part of the frontal lobes. They also monitored subjects a month later for urine nicotine metabolites and found the strong messages were associated with a decrease.

What this seems to indicate is that you have to grab people’s attention and deliver a persuasive message. What is still lacking from this research, however, is long term follow up.

Other research also indicates that the “scared straight” approach has limited long term utility. The strong message may benefit from the incremental gains offered by techniques such as motivational interviewing (engaging the viewer’s goals) and social norming (essentially peer pressure).

Conclusion
It seems that it would be highly cost effective to invest research dollars into improving the technology of altering public health behavior. There is no simple answer to this complex problem. No matter how you look at it, it’s very difficult to have a significant impact on such behaviors.

Likely any successful campaign will involve multiple components, individual counseling, PSAs, and regulations, each with an incremental effect but with an overall significant effect.

So far the most effective methods seems to be those that make it easier to engage in healthful behaviors and difficult to engage in risky behaviors. People still have choice, but the easy default choice is the healthy one.

Posted in: Public Health

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16 thoughts on “Science-Based Public Service Announcements

  1. Anti-smoking ads are too negative, the photos of diseased mouths, lung cancer patients dying on their beds, people just shut their mind off when they see the horrors. Nobody likes a doom prophet.

    The message needs to be more positive. Stop smoking and save 100 dollars a week. Be more attractive in social life. Wake up full of energy. Thats a better message.

  2. goodnightirene says:

    Public health advocates such as Marion Nestle preach this message (the default choice needs to be pushed by government) ad nauseum, yet her blog is flooded every time she writes about it by libertarian-types screaming “FREEDOM” and “DEATH TO THE NANNY STATE”. Take a look at the comments in the NY Times when Bloomberg’s soda proposal was overturned! Sure there were voices of support, but there was an outpouring of support for “making our own choices” and “get the govt out of my face”.

    Nobody seems to care what actual research says anymore. Concern for public health has fallen right along with the idea that government can be a positive force. We’ve become individualist fetishists. Corporations saw what happened with tobacco and have spent billions making sure it doesn’t happen with diet, and the public is mostly buying it right along with their oversized soda.

  3. FBA – Sounds reasonable, but do you have any evidence to back that up? That’s what really matters, otherwise we can pontificate all day long.

    GNI – I agree. We need a more nuanced conversation than simply – any regulation attempting to influence behavior is nanny-state overreach.

    The fact is, corporations manipulate us every day in many creative ways to maximize our spending behavior on their products. They do a lot of research, and often have evidence-based programs of manipulation (ie marketing). They want the easy default choice to be the one that makes them the most money. I am not blaming them for that – that is the system.

    I am all for the free market, but we need a thoughtfully regulated free market. Darwinian processes are powerful and we should leverage them to maximize our economy, but they are also blind. Just as they merrily lead species to extinction, Darwinian market forces can lead us through short-term gain to long-term ruin. For example, market forces have lead to a food industry that favors cheap, tasty, calorie-dense, super-sized food. This has had an unintended consequence of increasing obesity. So now we should think of ways of tweaking the market so that public health concerns are taken into consideration.

    Of course, the bogeyman of regulations is unintended consequences. This is why we need – evidence-based regulations.

  4. Scott says:

    Unintended consequences are not the only concern. There really are conflicting imperatives here – limiting government reach into people’s lives is genuinely desirable.

    How much benefit to public health does there have to be to justify a given level of regulatory intrusiveness? The extreme libertarian view that no level of benefit can ever justify regulation is entirely untenable IMO, but it’s equally the case that regulation can be too intrusive for the benefit provided – nanny-state overreach is a real thing, at least as a potential to be avoided.

    A nice problem in conflicting imperatives, which calls for a real discussion with careful consideration of just how much benefit given regulations really provide vs. how much regulation we as a society are willing to accept for that benefit. Too bad the stridency from the extremes (mostly the libertarian extreme, but I’ve seen some from the other end too) drowns out the details.

  5. weing says:

    I thought the USPSTF came out against PSAs. Oh. Nevermind. I think we should use the evidence based marketing that the corporations use for selling their products. This would mean war with the corporations for the minds of the population. They have the money. It’s a losing battle.

  6. Scott – I agree.

    Weing – I partly agree. But – we can use regulation to rig the game. PSAs alone probably won’t ever be enough if the corporations have free reign to rig the game in their favor.

  7. @Steven

    The negative campaigns have been studied, and they work on many, but there are groups of addicts that dont respond to fear-based warnings. There is some analysis of that here: http://bit.ly/ZN1wTm

    I dont have much data on tobacco campaigns that focus on a positive message, there are too few that have been tried. Here is one that is currently running and sends a positive message: http://bit.ly/17itY4Y

    My brother smokes and pulls out ciggies from a pack with pictures of rotten teeth and black tumors. It doesnt bother him. The mention of saving $4000 a year gets a better response.

  8. mousethatroared says:

    I too dislike the current crop of anti-smoking psa, with the poor woman ravaged by cancer. It smacks of the kind of voyeurism beloved by folks who frequent Ripley Believe It or Not Museum all wrapped up in a guise of a “Precautionary Tale”. What a victorian concept. I’ve never smoked and it makes me want to take up smoking, just to protest the general ickiness.

    I really dislike being preached at AND the kind of preaching I dislike the most is fire and brimstone. Although I was fascinated with Hieronymus Bosch when I was a kid. I wonder how effective that was in stopping the sinning.

    The question of positive vs negative campaigning is too simplistic, though. For instance, I believe that the Truth anti-smoking psa were considered to be effective. But they were primarily negative about the cigarette industry, not the habit of cigarette smoking. They reframed the debate in a way that showed how the cigarette companies make a profit from a dangerous product, rather than seeming to say “Haven’t you quite smoking yet…look at how terrible your habits are.”

  9. Harriet Hall says:

    The “Mister Yuk” stickers on medicine bottles didn’t dissuade children from sampling the contents; in fact, they attracted their attention. The effects of any intervention may have unexpected results; testing is essential.

  10. windriven says:

    PSAs don’t have to be one or the other. Sometimes it takes a hammer, sometimes it takes a rose. Use every tool in the PSA toolbox.

    It seems to me – and I have nothing empirical to back this up – that the message that smoking is for losers is among the most powerful. It is the other side of the old Madison Avenue technique that equates a product with sexual desirability. Smoke and you won’t get laid. Smoking gives women lizard skin and makes mens penises look small and smell bad*. Years ago there were the ‘kissing a smoker is like kissing an ashtray’ PSAs. They struck me as effective at the time. But that was a different time and place.

    *The lizard skin part is true and the rest is no worse than companies suggesting that smoking makes you virile and attractive.

  11. mousethatroared says:

    weing “I think we should use the evidence based marketing that the corporations use for selling their products.”

    Do corporation use evidence based marketing? There is sometimes the appearance of evidence, but often that “evidence” is put together by an ad agency who wants to get or keep the business and is putting together the evidence with an eye toward supporting their position. (Remember that wonderful super bowl, before the tech bubble burst, with all the creative .com commercials, were did those companies all go…) It’s a bit like the stock market or the real-estate market, there’s the appearance of rational thought, but those appearances can be deceiving.

    Actually, there’s a bunch of articles on medpub considering what’s effective in a PSA. I haven’t had time to peruse what looks good and what’s speculation. Maybe someone else would be interested.

    In the end, I think there’s a lot of art to the process, though.

  12. windriven says:

    @mouse

    “Do corporation use evidence based marketing?”

    Yes, evidence that their marketing is successful. That is quite a different matter than evidence regarding the underlying product.

  13. weing says:

    @MTR,

    “Do corporation use evidence based marketing?”

    I agree with windriven. Those commercials helped inflate the bubble. On a personal level, it, marketing, must be working, at least on physicians. Why are we no longer allowed to get drug company pens, etc or get sent on trips to resorts? They must have been influencing us. I think there is literature to support that. Apparently it doesn’t work on Obama and other politicians as they are immune for some reason.

    http://www.ijreview.com/2013/02/38468-not-a-joke-for-500000-you-can-have-access-to-president-obama/

  14. mousethatroared says:

    My point was not that marketing didn’t work. It was just that I’m not really sure how formally evidence based it is. I think some ad agencies are very into market research and others, not so much. They are just very good at selling their ideas to their clients…perhaps that is often good enough, because what we are talking about is selling ideas/communication. It’s like a good TV series or popular book…are they directed by formal evidence on what plot twists and characters will appeal to a broad audience or are they just written by people with good intuition and experience who know how to engage people in their story or message?

  15. mousethatroared says:

    Next we’ll consider the “evidence based” comedian. :)

  16. mousethatroared says:

    One more thought. The tech bubble was created by investors how threw money at any company with a .com in it’s name. The commercials were supposed to draw in customers, but not enough customers for too many companies=lots of dead companies. I don’t blame this on the commercials, they didn’t write the poor business plans of many of these companies. But, remembering working at a tech company at that time and remembering how money was flying around, I’d be pretty willing to bet that the Super Bowl ad spending was inspired much more by sky in the pie visions and ego than evidence/researched based marketing plans.

    Just my two cents

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