Monday, December 23, 2013

Public Health’s Attempt to Curb Teenage SSB Consumption Falls Short: A Critique on States Soda Ban in High Schools -Han Ling Cheng (Elly)

I. Introduction
Public health professionals and critics point out that carbonated sugar beverages are associated with more than 180,000 obesity-related deaths per year all over the world. (1) When people, especially adolescents take too many sugar beverages in their daily diet, the excessive calories may cause several kinds of chronic disease, such as obesity, cardiovascular disease, diabetes, and insulin resistance. These empty calorie beverages comprise a substantial percentage of caloric intakes among adolescences currently. Therefore, sugar sweetened beverages (SSB) have become a critical public health issue that are viewed as related to teenage obesity and obese related diseases. To combat childhood obesity, many states and some school districts have implemented a soda ban policy to limit high school students’ access to SSB. (2) After the policy was adopted, 14 states banned sodas in school vending machines, and other schools also banned them in cafeterias. (2) By the start of the 2009-2010 school year, six states prohibited all sugary drinks in high school vending machine, and six other states prevented students from accessing SSB in school cafeterias. (2) The School Beverages Guideline was established by the American Heart Association, American Beverage Association and Clinton Foundation to enhance the nutritional content of school beverages by the start of 2009-2010 school year as well. (3)    
Even though these policies were well intentioned and based on plausible logic to achieve the goal of reducing teenage SSB consumption, the act was not attractive to adolescents and didn’t result in a decrease of SSB consumption. (4) The states’ policies hope to change high school students’ SSB consumption behavior by reducing students’ opportunities of getting sodas. (5) But, in fact, schools are not a major source of SSBs for teenagers; they have many other convenient ways to gain access to these beverages. (6) The intention of these policies to reduce the amount of SSBs consumption via limited access failed, and there was only a modest association between decreased SSB access in schools and decreased SSB consumption. (5) States’ policies that prohibit all SSBs in high school vending machines or cafeterias reduced the SSB access in school for teenagers but did not show statistically significant evidence to demonstrate that access limitation did reduce the total SSBs consumption among adolescents. (5) The intention of the policies was to promote healthier drinking pattern by banning SSBs for teenagers to prevent them from becoming obese, but based on the information provided above, the policies failed to meet the goal. This critique will analyze three flaws of the SSB ban policies and provide three possible interventions to improve the result.

II. a. Banning Access to SSB Lacks the Means to Boost Self-Efficacy Towards Healthy Drinks
The states’ soda ban policies simply inhibited teenagers from gaining access to SSBs at school. The action itself did not provide adolescents with any implications about why or how to choose healthy drinks, and thus, failed to promote self-efficacy towards establishing a long-term healthy diet concept. Therefore, even if the access of SSBs slightly decreased for adolescences in high school, the total consumption did not decrease compared with states that did not adopt the SSBs access ban policies. (5) Lacking an appropriate direction to show children why or how to drink can’t lead them to a healthy diet path by simply banning SSBs in school. Children are just being asked not to drink SSBs but still keep their original diet pattern once they leave school. Although excessive intake of SSBs increase the future risk of developing diabetes, heart disease, and insulin resistance, teenagers feel it distant from these risks and their current lives. In sum, public health policies drew an image of SSBs and health together in an authoritative tone, non-engaging motives, and negative results if someone did not obey the admonition. The long-term chronic health diseases themselves were not powerful enough to boost teenagers’ self-efficacy to replace SSB with healthy drinks in their diet.
The reason why adolescents felt long-term chronic diseases distant from themselves can be explained by inter-temporal model of behavior change. When it comes to preventive behavior, a decision maker’s temporal preference is very important since it plays a decisive role in determining relative receptiveness of an preventive intervention. (7) Preventing children from accessing to sodas is a choice for kids to weigh between immediate pleasures and benefit of good health in the future. Since teenagers are obstinate and value happiness of the moment more than long-term health, they discount chronic obese-related diseases and don’t think of the possibility of developing them. (8-9) In addition, Kahneman and Tversk found asymmetry in risk aversion and concluded that certain to uncertain gains are preferred. Whereas, when it comes to losses, uncertainty to certainty is preferred. (10) Under the soda ban policy situation, the immediate action of giving up sodas gave children a high degree of certainty of loss while gaining good health in the future was uncertain. Thus, the high degree of certainty of loss induced children to act in exactly the opposite way from the policies intended them to do.  Consequently, the SSBs ban policy is flawed because it failed to consider the temporal preference in teenagers and lacked a clear frame to promote children’s self-efficacy toward healthy drinking habits. By simply suppressing adolescents’ desire of SSBs, the intention of policies was hard to attain.

II. b. How to Promote Self-Efficacy to Healthy Diet While Banning SSBs Access 
Considering the inter-temporal model-temporal preference of teenagers and the discount effect (8), improvement to advocating banning sodas to teenagers is to first identify the position of how teenagers relate to sodas. Do they consider the long-term consequences or do they simply make decisions based on their immediate benefit? By grasping this core way of thinking of children, we can frame a better story to promote their self-efficacy to replace sodas with water or milk. Teenagers’ concern about their daily life helps them to make decisions. They care about their appearance to the opposite sex, and they value the immediate happiness of sharing Coca-Cola together with friends. Hence, the SSBs consequences should be framed within some immediate reality that teenagers really care about instead of some distant future with chronic health diseases. According to Ortendahl’s article, effects are mostly temporary and viewing behavior as sequences of outcomes evidently has implications for behavior change effects are mostly temporary and viewing behavior as sequences of outcomes evidently has implications for behavior change”. (8) Therefore, for the second step, policy makers may articulate a specific benefit of not drinking sodas over a certain period of time or an immediate health problem they might encounter occurring at different time intervals if they keep drinking soda. The most direct problem adolescents can identify immediately with and care about the most is poor appearance. Considering this, we can frame our story related to immediate consequences such as increasing body weight (11) and having unhealthy teeth (12), which are easy to understand and imagine for teenagers. We should clearly demonstrate the advantages of giving up soda and the disadvantages of drinking them in small brochures and put them on every table in the cafeteria to remind children everyday.
            To promote the self-efficacy of choosing healthy drinks, we should use easy, clear and encouraging words with a specific time period to let children understand the consequences comprehensively. For example, drinking one soda per day for a month will cause tooth decay. If they keep drinking one soda per day for two months or more, their teeth will be discolored and it will be hard to recover their original color. We can also add some actual pictures along with the slogans to strengthen their power. With a clear sequence of time periods, it may be easier for teenagers to understand this negative consequence and link it to their daily lives. Or we can frame it in a positive way like mentioning the advantages of not drinking sodas. For example, if they do not drink sodas for a week, they may lose 0.7 pounds, and if they replace soda with water for one month, they may probably lose more than 3 pounds and look slimmer. Just a little will power for their choice and then they can make a big difference to their body shape and surprise their friends. Either way, these brochures provide teenagers with reasons they should quit drinking sodas and how they could take action to change their body and health. Adolescences can understand and visualize bad or good conditions and connect those impacts with their appearance in their day-to-day reality. With better framing stories in a brochure and clear guide of what to change, children will no longer feel the soda-related diseases distant from their daily lives and believe that it’s not too hard for them to change. When children start believing that they can actually do something about the changing their diet patterns to a healthier way, we better promote their own self-efficacy.

III. a. The SSBs ban Policies Failed to Take the Effect of Social Cognitive Theory into Account
            Adolescents’ minds are complex. Teenagers are not mature enough to be adults, but they are eager to grow up. They deal with all kinds of emotions during this period such as expectations from parents, peer pressure, and self-exploration. At this stage, the impact of peers and friends are huge.  The reason why the SSBs ban did not successfully decrease the consumption of SSBs can be explained by social cognitive theory. Social cognitive theory assumes that the three factors - environment, people and behavior - are constantly influencing each other. The theory concludes that portions of an individual's knowledge acquisition and decision-making patterns are associated with observing others within the context of social interactions, experiences, and other environmental influences. (13) Research has revealed that there is no significant evidence that the policies actually reduced the total SSBs consumption. (5) The researchers’ further supplementary analyses even showed that there was even a slight increase in frequent consumption of SSBs, implying that “heavier consumers compensated effect” cause increased consumption outside of school. (5) The soda ban implementation’s lack of considering social cognitive theory in the development of this policy may have increased the consumers’ compensated effect.
            Imagine if a group of teenagers decide to grab cokes at a convenience store together after school. Will a teenager say no to his/her friends just because of the health risks? The answer is probably not because teenagers will not break with their teen social norms easily. Teenagers value belonging with their peer group more than anything else, so when they see their peers drinking sods outside of school, they usually will join them. By contributing to activities with their friends, teenagers feel they are accepted as members of the group. Not being an outsider is much more important than an individual’s health consideration. (14) The reciprocal determinism of social cognitive theory explains why each teenager has such great power to affect the other. In addition, after being part of the group, there will be reinforcement of that behavior in a positive way. Although the policies ban the access to SSBs in school, they can’t change the whole environment. Drinking soda has been part of the culture of the United States and sodas are sold almost everywhere. Therefore, simply suppressing access to SSBs without implementing any other related policies is not going to achieve the intention of decreasing adolescent SSBs consumption. This may indicate why SSBs ban policies had modest outcome and could account for some adverse outcomes. (5)

III. b. Policy Makers Should Take Advantage of Social Cognitive Theory to Achieve the Goal
            How can public health policy take advantage of social cognitive theory to reduce total teenage SSBs consumption? The answer lies in changing the values inside adolescents’ minds instead of prohibiting access on the surface of this problem. Policy makers should come up with a strategy that will at least change some of the teenagers’ attitudes, and if they successfully change some teenagers’ drinking patterns, the rest will follow the new drinking pattern due to the power of social cognitive theory. Making an attractive advertisement related to a new drinking pattern and broadcasting them to students during school time is a way that would work. The soda industry has poured a lot of money into creating fancy advertisements that usually catch teenagers’ attention with strong core values such as freedom and happiness. The National Children’s Bureau (NCB) Report on 2006 about food and drink advertising and pointed out that “children are drawn towards (food) products that are heavily branded and marketed, which tend to be of little nutritional value”. (15) According to advertising theory, soda advertisements are more attractive, powerful, and persuasive to adolescents compared with healthy food advertisements. The soda industries market their products with movie stars, celebrities or sports heroes. They create an image that by drinking those sodas, adolescents feel cooler or more popular.
To promote healthy drinks, public health officials should think of a new way to frame advertisements of healthy drinking patterns. Policy-makers should explore techniques used in soda advertisements to create a new image of healthy drinks and make healthy drinking patterns themselves attractive and fashionable to youth. For example, creating a story within advertisements that fits teenagers’ social reality. The story could be about a group of popular basketball player drinking water and milk after winning a game, and teammates sharing their healthy drinks together on the go. This image will demonstrate core values such as autonomy and the coolness of healthy drinks to children. This new advertisement of water and milk will clearly convey that healthy drinks can also be part of the teens’ social norms and make healthy drinks as attractive as SSBs. The most important thing to change teenagers’ decision-making patterns and choose healthy drinks is to make them believe that when they drink water or milk, they fit in better with their peer group and feel their desire fulfilled with a strong sense of belonging. If policy-makers successfully create more attractive healthy drink advertisements, they may be able to change children’s drinking patterns. Once these patterns are changed, they will not trying to get more sodas after class dismissed even if soda access is limited at school. Finding a sense of belonging is the most important aspect of teens’ social reality. Thus, as long as policy-makers can connect healthy drinking patterns with peer belonging, they can exert the power of social cognitive theory to successfully reduce the total consumption of SSBs.

IV. a. The Violation of Psychological Reactance Theory
According to the psychological reactance theory, once people’s freedom is threatened, their first reaction is to restore their freedom by doing what they are asked not to do immediately. (16) People will want to protect their freedom right away. Whenever a free behavior is restricted, people will experience psychological reactance. (16) Banning SSBs access at school is sending teenagers a message that their freedom of choice is being deprived. Once teenagers experience reactance, they will feel that SSBs are even more attractive to them, and they will aim to restore their freedom by drinking more soda. (17) This act stimulates adolescents’ desire to drink more soda once they are able to buy it. This phenomenon also explains the reason why “heavier consumers compensated effect” may increase teenage SSBs consumption outside of school for states that adopted soda ban policies. (5) Because adolescence’s desire is suppressed at school, they try to protect their freewill by consuming more soda after the suppression is over.
Therefore, states SSBs ban policies are flawed because they violate the psychological reactance theory. Reactance will induce an unfavorable attitude towards the banning action that has been imposed. Prohibition of SSBs access may not achieve the intention that policy makers assumed to reach,; in contrast, the imposed behavior might foster teenager adverse attitude toward the restrictions. (18) Furthermore, reactance even stimulates adverse emotions towards the source of the restriction. (19) Banning soda access in high school may not help policy makers reduce the total SSBs consumption; in contrast, it may increase the possibility that children will consume more out of the will to defend their freedom.            

IV. b. The Ways to Avoid Psychological Reactance
            To avoid psychological reactance, health experts and policy makers should try to deliver their message in a way that caters to teenagers. Using the tactic of similarity can reduce psychological reactance and may gain a better passageway to touch adolescents’ minds effectively. Similarity enhances the positive force toward compliance via increasing liking. (20) If policy-makers can figure out some way to make adolescents like them, then this “liking” will increase their tendency to like what the policy makers like too. Similarity may decrease the negative force toward resistance and liking may increase the positive force toward compliance; these two elements together may possibly affect teenagers’ perspective towards soda ban policies.
            How can one create similarity along with the SSBs ban policies? Policy-makers can look for a group of teenagers of various in ethnicities and ages to deliver the message. Maybe they can produce a commercial or a promotional video talking about the main purpose underlying the SSBs ban policies. Teenagers will be more likely to accept a message that comes from their similar peer group because they will give more credit to the messenger’s words and connect the message with their social reality together. (21) Once adolescents feel that the person delivering the message has needs similar to their own, stand in their shoes, and has their perspective, children will establish a special credibility towards the messenger. (22) Adolescents will feel less threatened when accepting the message of the soda ban form peer-like people, who are less threatening so they will feel the resistant force weakened. Similarity deflects psychological reactance (22) and thus, the policies’ real intention of children reducing their total SSBs intake may be more easily achieved.
            The final way to deflect psychological reactance is not to challenge teenagers’ beliefs and values, but to reinforce them to support the soda ban policies. We need to understand the core value of why teenagers love sodas and frame healthier drinks such as water, skim milk, and orange juice in the same way as sodas. Framing good drinks with a creative approach and using messengers similar to teenagers’ social reality are necessary to show that good drinks are cool and children are “loving” it.

V. Conclusion
            Based on the evidence presented above, the SSBs ban policy adopted in high school is flawed. There are three reasons why the policy failed to reduce total consumption among adolescence. Among them, the lack of promotion of self-efficacy towards healthy drinking pattern, the lack of promoting the power of peers through social cognitive theory, and the lack of consideration of the psychological reactance theory. The three interventions or approaches I provided to correct those flaws are conveying clear, encouraging information with immediate outcomes and temporal sequences to children, creating belonging along with the ban policy to exert the power of social cognitive theory, and using similarity and the effect of liking to deflect psychological reactance.

VI. References
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