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Commentary: Morphing social norms through media messaging
NHTSA Notes
COMMENTARY: MORPHING SOCIAL NORMS THROUGH MEDIA MESSAGING [Pribble JM. Commentary: morphing social norms through media messaging. Ann Emerg Med. 2006;48:740-742.] Alcohol-involved driving remains a major factor in motor vehicle crash injuries and deaths. In fact, 39% of the 43,443 traffic-related deaths in 2005 involved alcohol in the United States. Moreover, young adults aged 21 to 34 years are disproportionately represented in alcohol-involved driving crashes.1 Emergency physicians have a critical role to play in decreasing the incidence of drinking and driving. We have the power to participate in changing social expectations in ways that may greatly benefit our patients and the public’s health. Social norms theory maintains that our behavior is strongly influenced by our perceptions of the attitudes and behaviors of our peers. Research has shown that people hold remarkably exaggerated views of the risk-taking behavior of their peers; they believe that “everybody” is engaging in drinking and driving at a much higher rate than is actually the case.2 These misperceptions may be formed when a few individuals are observed engaging in highly visible problem behavior (such as public drunkenness, impaired driving, or smoking) and when this extreme behavior is remembered more than responsible behavior that is more common but less visible.3 These misperceptions are assumed to be normative and may be spread further in “public conversation” by community members3 or disseminated by the mass media through news, entertainment, and advertising. The National Highway Traffic Safety Administration and researchers at Montana State University developed a social norms media campaign based on the social norms theory. The campaign aimed to correct commonly held misperceptions about drinking and driving and the use of a designated driver among individuals 21 to 34 years old. Montana’s “MOST of Us Don’t Drink and Drive” campaign used a quasiexperimental design in which the 15 westernmost counties received the media intervention, which included positive messages describing the actual norms of 21- to 34-year-olds’ behavior about drinking and driving and disseminated this information through a combination of paid television and radio advertisements. The remainder of the state was used as the control, which received public service announcements on donated airtime that may have included negative, fear-based messages. The Montana campaign’s outcomes demonstrate the usefulness of the social norms approach in changing societal misperceptions of drinking and driving behaviors among a highrisk population. Social norms are most effectively “spread” by seeing or hearing about the behavior in a number of different contexts and from a diversity of sources. Emergency physicians are in an ideal position to add their voices to this discussion and provide leadership within their local communities to reduce the impact of drinking and driving. 740 Annals of Emergency Medicine
EMERGENCY PHYSICIANS’ IMPACT ON SOCIAL NORMS IN THE EMERGENCY DEPARTMENT (ED) With nearly 8 million ED visits each year attributable to alcohol, 4 emergency physicians are uniquely situated to affect alcohol’s effect on the public’s health. Screening, brief interventions, and referral to treatment for alcohol misuse have been shown to be an effective means of improving alcohol behavior5 and this process within the ED has been recommended by a multitude of national professional health organizations and agencies. The American College of Emergency Physicians (ACEP) has developed a useful tool that can be used by emergency physicians to address drinking problems encountered in the ED6,7 (available at: http://risky.acep.org; http://www.acep.org/webportal/ PracticeResources/issues/pubhlth/alcscreen). The Web site details how emergency physicians can identify at-risk individuals and provide normative data so that counseling can use the social norms approach. A specific goal of the ACEP site includes resetting the social norms that most people do not drink in excess (defined by ⬎14 drinks/week and no more than 4 drinks at one time for men, and ⬎7 drinks/week and no more than 3 drinks at one time for women or anyone older than 65 years). Using these normative statistics helps provide a reference for emergency physicians to use when addressing social misperceptions within at-risk populations commonly treated in the ED. Some emergency physicians may be reluctant to perform screening, brief interventions, and referral to treatment for alcohol because of the Uniform Accident and Sickness Policy Provision Law. This law was instituted in 1947 and allowed insurance companies to deny payment for medical conditions or injuries caused by alcohol. Fortunately, the National Association of Insurance Commissioners has now advocated for the repeal of this law, which has been repealed in many states. The American College of Surgeons has also mandated that screening, brief interventions, and referral to treatment be included for credentialing of trauma centers (beginning in 2007).8 As such, the Uniform Accident and Sickness Policy Provision Law should not be a reason to forgo screening, brief interventions, and referral to treatment in the ED. One of the main differences between the experimental and control communities within the Montana campaign was the use of paid advertisements on television and radio. Using paid television and radio advertising space reaches many more people than public service announcements because public service announcements are most commonly aired between midnight and 6 AM.9 Using countermarketing by placing responsible alcohol use messages in paid television and radio spots is crucial to combat the nearly $1 billion annual advertising budget of the alcohol industry. Countermarketing has been shown to be extremely useful against smoking,10 and similar efforts are needed to reduce alcohol misuse by adolescents and young adults in this country. Emergency physicians should advocate for resources Volume , . : December
NHTSA Notes to support antialcohol countermarketing in efforts to reduce problem drinking through mass media campaigns. Emergency physicians can provide useful local data about risk factors, incidence, and common misperceptions, and as public health leaders in their community, they should be vocal leaders in support of such campaigns.
EMERGENCY PHYSICIANS’ IMPACT ON SOCIAL NORMS IN THE COMMUNITY Mass media campaigns have been shown to reduce alcoholinvolved motor vehicle crashes11 through direct effects on individual behaviors and through indirect effects influencing the injury policy agenda.12 The more often a specific topic is discussed by the media, the more salient the issue becomes to the public and policymakers. Aside from paid campaigns, the news media may seek to interview emergency physicians, police, firefighters, or emergency medical services (EMS) personnel after a particular local injury event. Emergency physicians need to be aware of the power of the mass news media and the tremendous opportunity provided by the mass news media to discuss important injury prevention strategies such as alcohol’s impact on driving and seatbelts. Of all the possible news media channels available, local television news is the number 1 source of information for the majority of Americans, by a margin of nearly 2 to 1.13 Motor vehicle crashes are the number 1 unintentional injury topic reported on local television news, representing nearly half of all unintentional injury stories reported on local television news (J. Pribble, written communication, October 2006). ACEP encourages police, firefighter, and EMS personnel to interact with the media during the reporting of acute injury events to promote injury prevention,14 and data have shown that police and firefighters are the most common individuals interviewed who could deliver a preventive message (J. Pribble, written communication, October 2006). Emergency physicians often provide medical direction to emergency personnel and should be intimately involved in training these individuals on how to interact with the news media so that important injury prevention messages can reach the community and influence social norms. Disseminating injury prevention information through the mass media also influences the injury policy agenda and may prompt legislative or community actions to combat the problem of drinking and driving. This pattern was demonstrated within the Montana study because the intervention group was much more likely than the control group to be in favor of reducing the legal blood alcohol concentration to 0.08, despite no messages about this topic being aired during the campaign. Again, emergency physicians should use their position within the community, along with the power of the mass media, to advocate for policy changes that will reduce the public health problem of alcohol. Results from Montana’s MOST of Us Don’t Drink and Drive campaign demonstrate the strength of paid television Volume , . : December
and radio countermarketing using a social norms approach in realigning the social norms surrounding drinking and driving. This campaign highlighted some useful strategies that can be used by emergency physicians to reduce the impact of alcohol on the public’s health. Emergency physicians need to recognize the importance of the mass media’s influence on injury prevention. Every opportunity to inform the public about the social norms of alcohol use and alcohol-involved driving should be used, including training police and firefighters on how to speak with the media. Finally, emergency physicians should use screening, brief interventions, and referral to treatment in hopes of changing social perspectives about alcohol misuse within the ED. Through these strategies, emergency physicians can provide needed leadership toward changing social expectations in ways that may greatly benefit our patients’ and the public’s health. REFERENCES 1. National Center for Statistics and Analysis. Alcohol-related fatalities and alcohol involvement among drivers and motorcycle operators in 2005. Available at: http://www-nrd.nhtsa.dot.gov/ pdf/nrd-30/NCSA/TSF2005/overviewTSF05.pdf. Accessed October 24, 2006. 2. Perkins HW, ed. The Social Norms Approach to Preventing School and College Age Substance Abuse: A Handbook for Educators, Counselors, and Clinicians. San Francisco, CA: Jossey-Bass; 2003. 3. Perkins HW. College student misperceptions of alcohol and other drug norms among peers: exploring causes, consequences, and implications for prevention programs. In: Designing Alcohol and Other Drug Prevention Programs in Higher Education. Newton, MA: Higher Education Center for Alcohol and Other Drug Prevention, US Department of Education; 1997:177-206. 4. McDonald AJ 3rd, Wang N, Camargo CA Jr. US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Arch Intern Med. 2004;164:531-537. 5. D’Onofrio G, Degutis LC. Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med. 2002;9:627-638. 6. American College of Emergency Physicians. Alcohol: how much is too much? Available at: http://risky.acep.org. Accessed September 6, 2006. 7. American College of Emergency Physicians. Alcohol screening and brief intervention in the ED. Available at: http://www.acep.org/ webportal/PracticeResources/issues/pubhlth/alcscreen. Accessed September 6, 2006. 8. Cherpitel CJ. Alcohol-related injury and the emergency department: research and policy questions for the next decade. Addiction. 2006;101:1225-1227. 9. Atkin C. The impact of public service advertising: research evidence and effective strategies [Kaiser Family Foundation Web site]. Available at: http://www.kff.org/entmedia/20020221aindex.cfm. Accessed April 12, 2005. 10. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs: August 1999. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1999.
Annals of Emergency Medicine 741
NHTSA Notes 11. Elder RW, Shults RA, Sleet DA, et al. Effectiveness of mass media campaigns for reducing drinking and driving and alcoholinvolved crashes: a systematic review. Am J Prev Med. 2004;27: 57-65. 12. Yanovitsky I, Bennett C. Media attention, institutional response, and health behavior change: the case of drunk driving, 19781996. Communication Res. 1999;26:429-453. 13. PEW Research Center for the People & the Press. Public’s news habits little changed by Sept. 11: Americans lack background to follow international news [Pew Research Center Web site].
Available at: http://people-press.org/reports/display.php3? ReportID⫽156. Accessed October 5, 2005. 14. Garrison HG, Foltin GL, Becker LR, et al. The role of emergency medical services in primary injury prevention: consensus workshop: Arlington, Virginia, August 25-26, 1995. Ann Emerg Med. 1997;30:84-91.
doi:10.1016/j.annemergmed.2006.10.005
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Visit www.annemergmed.com today to see what else is new online!
742 Annals of Emergency Medicine
Volume , . : December
COMMENTARY: MORPHING SOCIAL NORMS THROUGH MEDIA MESSAGING [Pribble JM. Commentary: morphing social norms through media messaging. Ann Emerg Med. 2006;48:740-742.] Alcohol-involved driving remains a major factor in motor vehicle crash injuries and deaths. In fact, 39% of the 43,443 traffic-related deaths in 2005 involved alcohol in the United States. Moreover, young adults aged 21 to 34 years are disproportionately represented in alcohol-involved driving crashes.1 Emergency physicians have a critical role to play in decreasing the incidence of drinking and driving. We have the power to participate in changing social expectations in ways that may greatly benefit our patients and the public’s health. Social norms theory maintains that our behavior is strongly influenced by our perceptions of the attitudes and behaviors of our peers. Research has shown that people hold remarkably exaggerated views of the risk-taking behavior of their peers; they believe that “everybody” is engaging in drinking and driving at a much higher rate than is actually the case.2 These misperceptions may be formed when a few individuals are observed engaging in highly visible problem behavior (such as public drunkenness, impaired driving, or smoking) and when this extreme behavior is remembered more than responsible behavior that is more common but less visible.3 These misperceptions are assumed to be normative and may be spread further in “public conversation” by community members3 or disseminated by the mass media through news, entertainment, and advertising. The National Highway Traffic Safety Administration and researchers at Montana State University developed a social norms media campaign based on the social norms theory. The campaign aimed to correct commonly held misperceptions about drinking and driving and the use of a designated driver among individuals 21 to 34 years old. Montana’s “MOST of Us Don’t Drink and Drive” campaign used a quasiexperimental design in which the 15 westernmost counties received the media intervention, which included positive messages describing the actual norms of 21- to 34-year-olds’ behavior about drinking and driving and disseminated this information through a combination of paid television and radio advertisements. The remainder of the state was used as the control, which received public service announcements on donated airtime that may have included negative, fear-based messages. The Montana campaign’s outcomes demonstrate the usefulness of the social norms approach in changing societal misperceptions of drinking and driving behaviors among a highrisk population. Social norms are most effectively “spread” by seeing or hearing about the behavior in a number of different contexts and from a diversity of sources. Emergency physicians are in an ideal position to add their voices to this discussion and provide leadership within their local communities to reduce the impact of drinking and driving. 740 Annals of Emergency Medicine
EMERGENCY PHYSICIANS’ IMPACT ON SOCIAL NORMS IN THE EMERGENCY DEPARTMENT (ED) With nearly 8 million ED visits each year attributable to alcohol, 4 emergency physicians are uniquely situated to affect alcohol’s effect on the public’s health. Screening, brief interventions, and referral to treatment for alcohol misuse have been shown to be an effective means of improving alcohol behavior5 and this process within the ED has been recommended by a multitude of national professional health organizations and agencies. The American College of Emergency Physicians (ACEP) has developed a useful tool that can be used by emergency physicians to address drinking problems encountered in the ED6,7 (available at: http://risky.acep.org; http://www.acep.org/webportal/ PracticeResources/issues/pubhlth/alcscreen). The Web site details how emergency physicians can identify at-risk individuals and provide normative data so that counseling can use the social norms approach. A specific goal of the ACEP site includes resetting the social norms that most people do not drink in excess (defined by ⬎14 drinks/week and no more than 4 drinks at one time for men, and ⬎7 drinks/week and no more than 3 drinks at one time for women or anyone older than 65 years). Using these normative statistics helps provide a reference for emergency physicians to use when addressing social misperceptions within at-risk populations commonly treated in the ED. Some emergency physicians may be reluctant to perform screening, brief interventions, and referral to treatment for alcohol because of the Uniform Accident and Sickness Policy Provision Law. This law was instituted in 1947 and allowed insurance companies to deny payment for medical conditions or injuries caused by alcohol. Fortunately, the National Association of Insurance Commissioners has now advocated for the repeal of this law, which has been repealed in many states. The American College of Surgeons has also mandated that screening, brief interventions, and referral to treatment be included for credentialing of trauma centers (beginning in 2007).8 As such, the Uniform Accident and Sickness Policy Provision Law should not be a reason to forgo screening, brief interventions, and referral to treatment in the ED. One of the main differences between the experimental and control communities within the Montana campaign was the use of paid advertisements on television and radio. Using paid television and radio advertising space reaches many more people than public service announcements because public service announcements are most commonly aired between midnight and 6 AM.9 Using countermarketing by placing responsible alcohol use messages in paid television and radio spots is crucial to combat the nearly $1 billion annual advertising budget of the alcohol industry. Countermarketing has been shown to be extremely useful against smoking,10 and similar efforts are needed to reduce alcohol misuse by adolescents and young adults in this country. Emergency physicians should advocate for resources Volume , . : December
NHTSA Notes to support antialcohol countermarketing in efforts to reduce problem drinking through mass media campaigns. Emergency physicians can provide useful local data about risk factors, incidence, and common misperceptions, and as public health leaders in their community, they should be vocal leaders in support of such campaigns.
EMERGENCY PHYSICIANS’ IMPACT ON SOCIAL NORMS IN THE COMMUNITY Mass media campaigns have been shown to reduce alcoholinvolved motor vehicle crashes11 through direct effects on individual behaviors and through indirect effects influencing the injury policy agenda.12 The more often a specific topic is discussed by the media, the more salient the issue becomes to the public and policymakers. Aside from paid campaigns, the news media may seek to interview emergency physicians, police, firefighters, or emergency medical services (EMS) personnel after a particular local injury event. Emergency physicians need to be aware of the power of the mass news media and the tremendous opportunity provided by the mass news media to discuss important injury prevention strategies such as alcohol’s impact on driving and seatbelts. Of all the possible news media channels available, local television news is the number 1 source of information for the majority of Americans, by a margin of nearly 2 to 1.13 Motor vehicle crashes are the number 1 unintentional injury topic reported on local television news, representing nearly half of all unintentional injury stories reported on local television news (J. Pribble, written communication, October 2006). ACEP encourages police, firefighter, and EMS personnel to interact with the media during the reporting of acute injury events to promote injury prevention,14 and data have shown that police and firefighters are the most common individuals interviewed who could deliver a preventive message (J. Pribble, written communication, October 2006). Emergency physicians often provide medical direction to emergency personnel and should be intimately involved in training these individuals on how to interact with the news media so that important injury prevention messages can reach the community and influence social norms. Disseminating injury prevention information through the mass media also influences the injury policy agenda and may prompt legislative or community actions to combat the problem of drinking and driving. This pattern was demonstrated within the Montana study because the intervention group was much more likely than the control group to be in favor of reducing the legal blood alcohol concentration to 0.08, despite no messages about this topic being aired during the campaign. Again, emergency physicians should use their position within the community, along with the power of the mass media, to advocate for policy changes that will reduce the public health problem of alcohol. Results from Montana’s MOST of Us Don’t Drink and Drive campaign demonstrate the strength of paid television Volume , . : December
and radio countermarketing using a social norms approach in realigning the social norms surrounding drinking and driving. This campaign highlighted some useful strategies that can be used by emergency physicians to reduce the impact of alcohol on the public’s health. Emergency physicians need to recognize the importance of the mass media’s influence on injury prevention. Every opportunity to inform the public about the social norms of alcohol use and alcohol-involved driving should be used, including training police and firefighters on how to speak with the media. Finally, emergency physicians should use screening, brief interventions, and referral to treatment in hopes of changing social perspectives about alcohol misuse within the ED. Through these strategies, emergency physicians can provide needed leadership toward changing social expectations in ways that may greatly benefit our patients’ and the public’s health. REFERENCES 1. National Center for Statistics and Analysis. Alcohol-related fatalities and alcohol involvement among drivers and motorcycle operators in 2005. Available at: http://www-nrd.nhtsa.dot.gov/ pdf/nrd-30/NCSA/TSF2005/overviewTSF05.pdf. Accessed October 24, 2006. 2. Perkins HW, ed. The Social Norms Approach to Preventing School and College Age Substance Abuse: A Handbook for Educators, Counselors, and Clinicians. San Francisco, CA: Jossey-Bass; 2003. 3. Perkins HW. College student misperceptions of alcohol and other drug norms among peers: exploring causes, consequences, and implications for prevention programs. In: Designing Alcohol and Other Drug Prevention Programs in Higher Education. Newton, MA: Higher Education Center for Alcohol and Other Drug Prevention, US Department of Education; 1997:177-206. 4. McDonald AJ 3rd, Wang N, Camargo CA Jr. US emergency department visits for alcohol-related diseases and injuries between 1992 and 2000. Arch Intern Med. 2004;164:531-537. 5. D’Onofrio G, Degutis LC. Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med. 2002;9:627-638. 6. American College of Emergency Physicians. Alcohol: how much is too much? Available at: http://risky.acep.org. Accessed September 6, 2006. 7. American College of Emergency Physicians. Alcohol screening and brief intervention in the ED. Available at: http://www.acep.org/ webportal/PracticeResources/issues/pubhlth/alcscreen. Accessed September 6, 2006. 8. Cherpitel CJ. Alcohol-related injury and the emergency department: research and policy questions for the next decade. Addiction. 2006;101:1225-1227. 9. Atkin C. The impact of public service advertising: research evidence and effective strategies [Kaiser Family Foundation Web site]. Available at: http://www.kff.org/entmedia/20020221aindex.cfm. Accessed April 12, 2005. 10. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs: August 1999. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1999.
Annals of Emergency Medicine 741
NHTSA Notes 11. Elder RW, Shults RA, Sleet DA, et al. Effectiveness of mass media campaigns for reducing drinking and driving and alcoholinvolved crashes: a systematic review. Am J Prev Med. 2004;27: 57-65. 12. Yanovitsky I, Bennett C. Media attention, institutional response, and health behavior change: the case of drunk driving, 19781996. Communication Res. 1999;26:429-453. 13. PEW Research Center for the People & the Press. Public’s news habits little changed by Sept. 11: Americans lack background to follow international news [Pew Research Center Web site].
Available at: http://people-press.org/reports/display.php3? ReportID⫽156. Accessed October 5, 2005. 14. Garrison HG, Foltin GL, Becker LR, et al. The role of emergency medical services in primary injury prevention: consensus workshop: Arlington, Virginia, August 25-26, 1995. Ann Emerg Med. 1997;30:84-91.
doi:10.1016/j.annemergmed.2006.10.005
Did you know? You can track the impact of your article with citation alerts that let you know when your article (or any article you’d like to track) has been cited by another Elsevier-published journal.
Visit www.annemergmed.com today to see what else is new online!
742 Annals of Emergency Medicine
Volume , . : December