The following originally appeared on The Upshot (copyright 2017, The New York Times Company) and is jointly authored by Austin Frakt and Keith Humphreys. Keith is the Esther Ting Memorial Professor at Stanford University School of Medicine. He has advised several government bodies, including the White House Commission on Drug Free Communities. This also appeared on page A11 of the November 2, 2017 print edition.
In declaring the opioid epidemic a public health emergency last week, President Trump promised that the federal government would start “a massive advertising campaign to get people, especially children, not to want to take drugs in the first place.” But past efforts to prevent substance abuse through advertising have often been ineffective or even harmful.
Perhaps the most famous American antidrug advertisement featured a sizzling egg in a frying pan to the sound of ominous music and a stern voice-over warning, “This is your brain on drugs.” A sequel to this ad featured Rachael Leigh Cook smashing an egg and the better part of a kitchen to dramatize the impact of heroin.
Many other ads denouncing drugs and emphasizing their destructive effects — as in the “Just Say No” campaign — appeared regularly on television and in print beginning in the 1980s. Most of them were funded by the White House Office of National Drug Control Policy, which received hundreds of millions of dollars a year from Congress for such campaigns.
Visually dramatic though the ads were, evaluations of them were deeply discouraging. The billions spent from the late 1980s through the mid-2000s at best had no effect on drug use, research shows. At worst, exposure to the campaign might have actually increased the likelihood of adolescent marijuana use. A study of over 20,000 youths 9 to 18 found that those who had been exposed to more antidrug ads expressed weaker intentions to avoid marijuana and more doubts that marijuana was harmful.
Why was the original campaign such a failure? In part it suffered from perverse incentives. Congress provided substantial money for the ads and was intensely interested in them at the height of the so-called war on drugs, creating internal pressure to make the ads appealing to members of Congress. But while ads that lectured or scared people about drugs might have seemed compelling to the modal member of Congress (a 60-year-old white male), they did not necessarily dissuade drug use by adolescents. In some cases, this kind of approach may make drugs more attractive as a sign of rebellion.
Other reasons that campaigns backfire is that they make adolescents aware of a drug that they might not have heard of, sparking curiosity in some to try it. Campaigns against drugs can also create a false sense that drug use is more common than it is, making those who don’t use drugs feel socially abnormal.
After the failure of the government’s initial antidrug media campaign, which was highlighted in the press and congressional hearings, it was significantly redesigned. The new approach, named Above the Influence, moved more toward the message that not using drugs exemplified and maximized youth freedom.
The retooled campaign had stronger results, with one study of over 4,000 adolescents showing that it reduced teenage marijuana use.
In switching tack, antidrug campaigns were taking a page from antismoking campaigns like the “truth.”This campaign, which research has estimated has deterred hundreds of thousands of adolescents from beginning to smoke, turns youthful rebellion to its advantage. Refraining from smoking was not about pleasing a parental authority figure; the “truth” pointed out to adolescents that people their parents’ age ran the tobacco companies and took them for saps (not cool). To be free thus meant to snub their seduction (cool).
Still, the positive results for Above the Influence and the “truth” are not the norm. A recent Cochrane review of rigorous studies collectively examining over 180,000 people reported that the average effect of mass media campaigns on drug use in randomized studies was essentially zero. Why is it so hard for media to change young people’s drug use?
By the time they reach adulthood, Americans are typically exposed to tens of thousands of advertisements promoting substance use, be it beer, cigarettes or more recently cannabis in some locations. Although opioids are not directly advertised to the public, seeking relief through pills certainly is (“Ask your doctor about …”).
Given this environment, it is not surprising that the comparatively small number of ads promoting the opposite message do not make much difference. In fact, it would probably be more consequential as a media strategy to stop the promotion of addictive products, but American courts are almost alone in the developed world in treating commercial speech comparably to the protection given free speech.
Media campaigns against drug use by young people thus can at most make a modest contribution to turning around the opioid epidemic, with some risk of making it worse if the lessons of past failed antidrug campaigns are not heeded. But the safest bet is that the results will be between those two end points: zero. To fight the opioid crisis, public money is probably best spent elsewhere.