Introduction
In August 2009 the New York City Department of Health and Mental Hygiene announced a new campaign to reduce the consumption of sugary drinks (1). This ongoing campaign consists of TV spots and printed advertisements placed on subway cars, and is supplemented by information posted on their website. Most of the ads and videos contain a hashtag with the phrase “Pouring on the Pounds” or the question, “Are you pouring on the pounds?”
The Pouring on the Pounds (POP) ad campaign was initiated to help decrease sugary drink consumption, thereby reducing the rates of obesity and diabetes—and related complications— among both children and adults. While some of the ads were powerful with the necessary shock factor needed to engage a public audience, others failed to have the impact that they could have. This paper critiques certain POP ads as ineffective because 1) they are fear based, 2) they rely on the health belief model without providing strong cost-benefit elements, and 3) they fail to acknowledge the role of herd influence and social conformity.
Critique 1: Fear Based Advertising
Several of the POP television ads focus on scaring people into compliant behavior – drinking fewer sugary drinks. One ad in particular explains how overconsumption of sugary drinks “eventually can bring on obesity and diabetes and its serious complications,” which can then lead to blindness, amputations, and even death (2). Part of the ad shows an image of two bandaged feet with toes missing, followed by an open body that is being operated on with the sound of a heart monitor beeping in the background. The machine switches from regular beeping to a high-pitched continuous beep, signaling that the patient has flat-lined and died. While it is true that poorly controlled, untreated diabetes can lead to death, linking sugary drinks to death in a 30 second ad is a bit extreme and unlikely to promote behavior change, as is supported by research on fear based health appeals.
According to Soames Job, a professor and researcher at University of New South Wales, fear based appeals are often met with little success in health promotion campaigns. An effective campaign, however, “allows for the desired behavior to be reinforced by a reduction in the level of fear…This entails five requirements: 1) fear onset should occur before the desired behavior is offered; 2) the event upon which the fear is based should appear to be likely; 3) a specific desired behavior should be offered as part of the campaign; 4) the level of fear elicited should only be such that the desired behavior offered is sufficient to substantially reduce the fear; 5) fear offset should occur as a reinforcer for the desired behavior, confirming its effectiveness” (3).
The ad described above does not meet all of these requirements. To proceed numerically, the ad does meet the first requirement by describing the terrible complications that can accompany diabetes before proposing that limiting sugary drink consumption can reduce the likelihood of developing diabetes. Criterion two, however, is not met. While it is true that drinking too many sugary drinks can contribute to becoming obese, which can then contribute to developing diabetes and further lead to amputations or death, the feared outcome is a result of a poorly treated medical condition that usually takes many years to develop and is a result of many prior health issues. A person does not become obese or diabetic overnight and does not develop a severe foot infection that requires amputation quickly either. Frankly, the allusion that sugary drinks lead to amputation and death is a stretch and is not likely for most individuals, particularly not in the immediate future.
Criterion three is met as reducing sugary drinks is a proposed solution to prevent obesity, diabetes, and related complications. Criterion four, however, is unlikely to be met because a) most people will not be fearful of amputations and death as previously discussed and b) those who are afraid of these complications, perhaps because they are obese or diabetic are unlikely to see reducing sugary drinks as sufficient to reduce this fear. I make this assertion because many people know that reducing sugary drinks can have a positive impact on weight and diabetes control, but this single change is unlikely to have a major impact on someone’s health without other significant changes in diet and exercise, especially if a person’s health is poor enough to warrant this fear.
Proceeding to criterion five, fear offset is unlikely to reinforce the desired behavior. As with criterion four, most people will either be unafraid or will be in such poor health that simply reducing sugary drinks will not reduce their fear. Consequently, based on Job’s research, this ad is unlikely to lead to significant behavior change.
Further research supports this assertion. Doctors Witte and Allen also did a meta-analysis of fear appeals in relation to public health. While they found that strong fear appeals are more persuasive than low fear appeals, “strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses” (4). I believe this research is in concordance with Job’s conclusions. This ad utilizes a very strong fear appeal—amputation and death are severe complications of diabetes. However, reducing sugary drink consumption does not seem like it will prevent these complications independently, thereby making it a low-efficacy message. Thus, individuals who drink excess sugary drinks may be prompted to defend their choice, either asserting that such extreme complications are unlikely and will not happen to them, or if they are overweight and/or diabetic, perhaps blaming their medical conditions on genetics or some other comorbid health issue that they do not believe they have any control over. It is also possible that individuals who consume many sugary drinks may justify such behavior as something that brings them joy, which may be difficult to come by if they experience a reduced quality of life due to obesity and/or diabetes.
The impact and effectiveness of fear based health promotion messages has been studied and is only effective in certain circumstances. This particular ad, however, fails to meet the necessary criteria needed to positively impact behavior change as the feared outcome highlighted is so extreme that it will not induce fear in many viewers, and may cause those who actually are morbidly obese or have poorly controlled diabetes to either simply ignore the message because reducing sugary drinks does not seem like it will have a large impact or defend their choice to drink sugary beverages. Additionally, such individuals are likely to feel stigmatized by this ad, further raising their defenses.
Critique 2: Health Belief Model – Cost Benefit Analysis May Not Lead to Desired Results
The health belief model is based on the idea that people make health decisions by doing a cost-benefit analysis (5). The perceived severity and susceptibility to a disease is weighed with the perceived benefits and costs of taking a certain action. The ad previously described utilizes the health model by insinuating that anybody who drinks too many sugary drinks is susceptible to becoming obese and developing diabetes, from which severe complications may result, such as amputation or even death. The ad further implies that the action needed to prevent this is simply to switch to water, seltzer, unsweetened tea or fresh fruit. With this “simple” switch, one can be healthy and avoid severe complications. However, for those individuals who do base their behavior on a simple cost-benefit analysis using this ad, the cost of giving up sugary drinks might be too great to warrant replacing them with less sugary alternatives and/or the perceived benefits might not be great enough to warrant the change.
First, individuals feel ownership over their behavior and giving up a particular behavior can be costly, especially if the behavior is automatic and provides a sense of normalcy and comfort, as may be the case when it comes to drinking sugary drinks (6). This concept is related to choosing to partake in identity-related experiences and behaviors, which can lead to personal happiness (7). While it is easy to tell someone to drink more water and fewer sodas, people often feel a loss when they give up a behavior that plays a recurring part in their life, making it difficult to change that behavior. For example, one study found that teens who planned to be abstinent often were not when faced with temptation. The core idea behind telling people to just say no “assumes that we can turn off our passion at will, at any point, whereas our study shows this assumption to be false” (8). This is likely true of sugary drink consumers as well; just telling them what to do is unlikely to be effective and giving up a favorite beverage may simply be too costly, especially if someone identifies as, say, a Pepsi drinker as opposed to a Coke drinker.
Beyond the cost, this ad portrays amputation and death as the worst outcomes that may arise from obesity and poorly controlled diabetes. Most people who view this ad are not going to view themselves as highly susceptible to either of these outcomes—because they aren’t. Even the average person with diabetes only has roughly a 0.28% chance of having an amputation in any given year, and that includes those who make no effort whatsoever to control their condition (9). While the severity of these outcomes is high, the lack of perceived susceptibility undermines that severity as a force to help people change behavior.
Similarly, the benefits of limiting sugary drink consumption are presented as the avoidance of obesity, diabetes, and resulting complications. However, this ad primarily targets those who do not already have these conditions by saying that over time drinking sugary drinks can lead to such complications, and therefore healthier beverage consumption should start now. However, the perceived benefit of preventing a condition that the person does not have is not very strong. As explained by two university researchers, Resnick and Siegel, “The person is more likely to choose a benefit he or she will obtain immediately…The delay associated with the long-term benefit results in the person discounting that benefit’s value” (10). In other words, the POP ad would have been much stronger if the benefit presented could be experienced or obtained in the present.
Overall, this ad is presented in such a way that the cost of giving up sugary drinks is unlikely to be greater than the benefits, and therefore does not utilize the health belief model in an effective way.
Critique 3: Health Belief Model – Doesn’t Account for Environmental Factors
While the health belief model relies on individuals doing a cost-benefit analysis when they make decisions, many individuals do not do a cost-benefit analysis because they are influenced by environmental factors, such as affordability, accessibility, herd mentality and social conformity. (It is also likely that some individuals do a cost-benefit analysis, but are swayed to make decisions that conflict with the health based analysis due to the social determinants listed above.)
Studies have shown that many individuals choose to drink whatever is convenient, accessible, and affordable. For example, an observational study conducted among 13 schools in Massachusetts found that 71% of sixth and seventh graders who used vending machines available at school purchased a sweetened beverage (i.e., Frutopia, tea, sports drinks, etc.) or regular soda in the previous 7 days (11). Following sweetened beverages other than soda, water was the most frequently purchased beverage. Had sweetened beverages been absent from these vending machines, it is likely that students would have consumed fewer sugary beverages and more water simply because the sweetened beverages would have been more difficult to obtain during the school day. Thus, availability, an environmental factor, can lead to greater behavior change than solely relying on an individual to perform a cost-benefit analysis.
In addition to purchasing drinks that are accessible, individuals also fall victim to herd mentality and social conformity, which are not accounted for by the health belief model (12, 13). Herd mentality and social conformity involve making decisions based on what others have done, leading people to change their opinions and make choices that help them coalesce with the group. Herd mentality occurs when individuals do whatever the group is doing without really thinking about it. For example, when “the wave” goes around a sports stadium the sports fans are engaging in herd mentality. They raise their arms because many people before them have done it. Most do not think about why they are raising their arms or the pros and cons of such a decision—they simply act.
Social conformity is similar in that people do things to fit in and avoid being perceived as “different.” This can be an intentional decision or something that happens quickly on a subconscious level. Let’s imagine a young adult at a dinner party. The hostess asks five people what they want to drink before her and they all ask for Pepsi. When the young lady, the sixth person in line, is asked, she quickly replies, “Pepsi, please.” Perhaps she is conforming intentionally; it is also possible that she answers quickly simply because everyone else had said Pepsi and it is easy to give this reply.
The dinner party scenario parallels findings from research studies and likely represents how many individuals make beverage choices on a day-to-day basis. For example, this fictional scenario is supported by the Asch line study in which a participant is shown a line and verbally asked to choose which of 3 different lines is the same length (13, 14). This task, however, is completed in a room with four confederates who all choose a line before the participant, often giving the incorrect answer. Each participant completed 12 line judgments and approximately 75% of these participants gave the incorrect answer at least once when the majority of the confederates gave the incorrect answer first. Also, “an average of 35 percent of the overall responses conformed to the incorrect judgments rendered by Asch’s accomplices” (13). When performing this task alone, participants almost never erred.
The point is that people are not doing cost-benefit analyses every time they make a decision. They are also influenced by herd mentality and a human tendency to conform to what others are doing around them. Therefore, the health belief model is inadequate to promote major behavior change for an activity that is often done in public, such as drinking a beverage.
Intervention Strategy
I propose changing three major aspects of the POP campaign. First, the ads based on scare tactics needs to be removed entirely and replaced with ads that use marketing theory and feature people similar to the target audience. Second, school vending machines need to stop selling sodas and sweetened beverages. And third, corner stores need to place unsweetened beverages at the front of stores, in more prominent locations.
An ideal ad could consist of two teenage friends at a vending machine. One asks the other what she wants to drink. We see a quick flashback of her on the cheerleading squad taking a sip of water after completing a complicated stunt. We also see her walking her dog with her brother, water bottle in hand. Upbeat music plays in the background. Back in real time, she asks for water. Her friend says, “Really? There’s soda in here too.” “Really,” she replies. “I don’t want to end up on the sidelines because I drank too much sugar.” “Good point,” her friend says. “I guess I’d rather not pour on the pounds either.” The friend then purchases two waters and they walk off happily together.
Defense 1: Replace Fear-Based Appeals with Advertising Theory
As explained in the first critique, fear appeals are often unsuccessful. I propose removing them entirely and replacing them with ads that take advantage of advertising theory, a model successfully used by corporate America to sell billions of dollars of product every year, ranging from cosmetics and clothing to cars and electronics. There is no reason why such tactics cannot also be used for health promotion.
Advertising theory has three major components: a promise, support, and core value (15). A well-done ad must tie all of these elements together in way that has universal appeal. The ad described above successfully accomplishes this. First, it promises that drinking water will both enable people to be included with their peers and family, and maintain a lifestyle they already enjoy. This message has a universal appeal because human beings are hardwired to seek social acceptance and support. For example, adults older than 65 who had impaired perceived social support had 3.86 times the mortality risk compared to adults in the same age group with unimpaired perceived social support (16). It is also common knowledge that teenagers give in to peer pressure in order to fit in and feel accepted. One retrospective study found that, “One-third of both genders identified peer pressure as one of the hardest things they had to face as a teenager” (17).
This ad also has strong support and core values. The flashback images are very positive and supported by positive music. They are intended to evoke an “I want that too!” response in the viewer. This ad tells the viewers that drinking water instead of sugary beverages will give them the freedom to live the life they want, surrounded by friends and family, unhindered by excess weight. As freedom and inclusion are very strong core values, this ad is likely to be successful.
Defense 2: Strengthen Cost-Benefit Elements
Some individuals do indeed do a cost-benefit analysis when making decisions. As previously discussed, the cost of giving up sugary drinks will be too high for many people, especially if they do not perceive themselves as being susceptible to the horrible complications that can result from untreated diabetes. The ad described above, however, has lowered the cost of cutting out sugary beverages by using speakers with whom the viewer can relate. Additionally, the implied outcome of consuming sugary drinks has been changed to something more realistic, therefore increasing perceived susceptibility. In the immediate future, individuals are more likely to become winded while walking their dog or have trouble playing sports due to weight gain. Having an amputation or dying as a result of diabetes complications is far less likely and difficult for most people to relate to (18).
By delivering the message by people who are similar to the viewer, the new ad utilizes communication theory and reduces reactance. According to communication theory, people relate and respond more positively to messengers that they can relate to. Research suggests that, “Similarity can increase the positive force toward compliance by increasing liking for the communicator” (18). This is why the ad features average teenagers, as opposed to an unseen narrator as used in the critiqued POP ad. Similar versions of this ad can be made to addresses other target populations, such as working mothers or children.
Psychological reactance theory, on the other hand, explains that people will hold onto something tighter when they perceive that it will be taken away (18). This is why the ad focused on the girl maintaining what she had: positive, fun interactions with her team, brother and dog. Instead of taking away her freedom (to drink sweetened beverages), avoiding sugary drinks allows her to keep it. Additionally, since this girl is an average teenager her similarity can help reduce reactance among teenage viewers. Again, research shows that, “similarity can reduce the negative force toward resistance by fostering positive interpretations of the communicator’s actions, particularly the degree of threat in the message” (18). Based on these theories, having a similar speaker who focuses on the benefits of drinking water will help lower the perceived cost of limiting sweetened beverage intake.
Defense 3: Change Behavior First
It is possible to use herd mentality to help further a public health cause. The key is to change behavior first. If people change their behavior, their beliefs will follow because people experience discomfort when their actions are not aligned with their values, leading to cognitive dissonance (19).
The diffusion of innovations theory involves getting a few people to adopt a behavior, which, upon reaching a tipping point, will lead to many people adopting that behavior (20). This theory also applies to schools and companies, not just individuals. Once a few schools remove sugary drinks from vending machines, more schools are likely to follow, and some people will drink fewer sugary drinks and come to value that decision as a result of cognitive dissonance. The same is true of placing sugary drinks in less prominent store locations and moving unsweetened beverages to the front of the store. As more and more people adopt this healthier behavior, it should catch on and become more commonplace.
It is also important to discuss how to convince schools and corner stores to make this change. Ideally, either a law would be passed or the schools and corner stores would receive a financial incentive, perhaps from the government or an NGO, to offer healthier options. However, if this was not the case, successfully lobbying even a few schools and corner stores could make a huge difference and lead to a diffusion of innovation. Once these few schools and stores change to emphasize the purchase of unsweetened beverages, it is likely that more will follow. For instance it is plausible that health conscious parents will advocate for healthier vending machine options in their own children’s schools upon hearing of this innovation at other schools. As a result, an increasing number of schools might jump on the bandwagon, thereby leading students to change their behavior, accomplishing the whole point of the intervention.
Overall, improving the ads, removing sweetened beverages from school vending machines, and placing unsweetened beverages in prominent storefront locations will bring the Pouring on the Pounds Campaign increased success.
References
1. The New York City Department of Health and Mental Hygiene. Press: New Campaign Asks New Yorkers if They’re “Pouring on the Pounds.” http://www.nyc.gov/html/doh/html/pr2009/pr057-09.shtml
2. The New York City Department of Health and Mental Hygiene. Pouring On the Pounds Ad Campaign Archive. http://www.nyc.gov/html/doh/html/living/sugarydrink-media-archive.shtml
(* Ad cited is the first one on the above page)
3. Soames Job, R. F. Effective and ineffective use of fear in health promotion campaigns. American Journal of Public Health 1988; 78(2):163–167.
4. Witte, K., & Allen, M. A meta-analysis of fear appeals: implications for effective public health campaigns. Health Education & Behavior 2000; 27(5):591–615.
5. Edberg, M. Individual health behavior theories (pp. 197-211). In: Edberg, M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.
6. Pierce J.L., Kostova, T., Dirks, K.T. The state of physhological ownership: Integrating and extending a century of research. Review of General Psychology 2003; 7(1): 84-107.
7. Palen, L., Coatsworth J.D. Activity-based identity experiences and their relations to problem behavior and psychological well-being in adolescence. Journal of Adolescence 2007; 30(5): 721-737.
8. Ariely, D. The influence of arousal (pp. 119-138). In: Ariely, D. Predictably Irrational. New York, NY: HarperCollins, 2009.
9. American Diabetes Association. Statistics About Diabetes. http://www.diabetes.org/diabetes-basics/statistics/
10. Resnick, E., Siegel, M. Introduction to Marketing Principles (pp. 87-111). In Resnick, E., Siegel, M. Marketing Public Health. Burlington, MA: Jones and Bartlett Learning, 2013.
11. Wiecha, J. L., Finkelstein, D., Troped, P. J., Fragala, M., & Peterson, K. E. School vending machine use and fast-food restaurant use are associated with sugar-sweetened beverage intake in youth. Journal of the American Dietetic Association 2006; 106(10):1624–1630
12. Thaler, R., Sunstein, C. Following the herd (pp 53-73). In: Thaler, R., Sunstein, C. Nudge. United States: Caravan Books, 2008.
13. Aronson, E., Aronson, J. Conformity (pp 13-58). In: Aronson, E., Aronson, J. The Social Animal. New York, NY: Worth Publishers, 2007.
14. Asch, S. E. Effects of group pressure upon the modification and distortion of judgment. In: Guetzkow H, ed. Groups, Leadership and Men. Pittsburgh, PA: Carnegie Press, 1951.
15. Resnick, E., Siegel, M. Marketing Public Health. Burlington, MA: Jones and Bartlett Learning, 2013.
16. Blazer, D. G. Social support and mortality in an elderly community population. American Journal of Epidemiology 1982; 115(5):684–694.
17. Brown, BB. The extent and effects of peer pressure among high school students: A retrospective analysis. Journal of Youth and Adolescence 1982; 11(2): 121-133.
18. Silvia, P.J. Deflecting reactance: the role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(3):277-284.
19. Aronson, E., Aronson, J. Self-Justification (pp 181-252). In: Aronson, E., Aronson, J. The Social Animal. New York, NY: Worth Publishers, 2007.
20. Rogers E. Diffusion of Innovations Fifth Edition. New York, NY: Free Press, 2003.
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