The Island Wide Substance Use Disorder (SUD) Coalition is an association of concerned citizens and health and social service organizations. A public health committee (of which I am a member) has been meeting every other week, with the goal of “designing and implementing a public health campaign to develop and promote a model where responsible use of alcohol and drugs replaces the current permissive culture of alcohol and drug use. The goal is to eliminate or at least delay the use of drugs and alcohol by youth, and encourage a standard for adults where alcohol or drugs are used mindfully, in a manner that does no harm to self, family, or community.”
Remember “Just say no”? Or “This is your brain on drugs”; “Choose to refuse”; “Cocaine, heroin, ecstasy, meth … All roads lead to death”? How effective have those public health campaigns been? During their heyday, the rates of drug and alcohol use ballooned. As it turns out, the power of scare tactics to change behavior is pretty weak. You might think that the long string of drug overdoses on the Vineyard would have led people with opioid dependence long ago to seek help and decide to stop using. But the nature of the disease pushes back against such rational action. Just recently, we saw another local death from overdose. People with this disorder frequently tell me that when they hear about a death from drug use, their first thought is “My god, that must have been good stuff; I wonder where I can get some.” Most past anti-drug campaigns clearly haven’t worked. But it should be possible to create a public health campaign that actually impacts culture and behavior.
Certainly the marketing of alcohol, marijuana, and other drugs has been effective in our culture — and not just the marketing done by big businesses. Kids in schools successfully market the use of mind-altering substances to one another, perhaps especially marijuana. Adults use similar conversations with friends to learn about substances. According to the local “Youth Risk Behavior Survey” in 2014, 41 percent of Vineyard high school students thought that regular marijuana use was risky; by 2016, only 28 percent thought it was risky. Since then, it has become legal, and the idea that it is a natural medicine has been widely promoted. (See my article “Weed and the developing brain,” bit.ly/OMMWeed, to understand how dangerous it is for youth.)
The “coolness” of drinking beer, wine, and other forms of alcohol is promoted through movies, ads, social media, and vigorously through the grapevine. So if promotion of alcohol and drugs works, the public health committee reasons, so can the promotion of health. We just have to find access to the right technology to make that happen. As it turns out, marketing firms have been exploring the same technology, and some have been successful. We needed to find an experienced partner.
After vetting several firms, the committee has selected the nonprofit Public Good Projects (PGP) to assist in carrying out a campaign. Some of the firms that were considered proposed polished campaigns that made assumptions about the Vineyard without really knowing it or understanding the nature of substance use disorders, and some created ads that would appeal to older people, but not necessarily to kids. According to PGP’s website (publicgoodprojects.org), its approach creates “groundswell movements for health and provides a dramatic alternative to current large-scale behavior change campaigns.”
I spoke with Dr. Joe Smyser, PGP’s chief executive officer, who has a Ph.D. and master’s in public health. He told me that the large-scale, top-down public health campaigns many associate with success, like the D.A.R.E. campaigns of the 1990s to early 2000s, are in reality not often effective. “Everyone believed D.A.R.E. was working at the time, but when it was rigorously evaluated, it turned out that it didn’t prevent children from using drugs, and D.A.R.E. revamped its program as a result in the early 2000s.”
He continued, “A major flaw in most large-scale behavioral change campaigns is that they are designed and implemented by marketing firms. The gold standard of these marketers is whether their advertisements reach large numbers of people, and whether those people remember a catchy tagline — measures that we know matter when someone is choosing which shampoo to buy, but there is so much more involved when carrying out public health efforts.”
PGP has a four-phase approach: Research, strategy, activation, and evaluation. One of their mantras is “Understand. Then act.” In the first phase, we will work with PGP to scour the literature, and work with stakeholder networks and individuals to understand the problem on a local level. And we will consider how to measure the impact of a campaign. The Vineyard is ideal because we already have so many invested community members and institutions. They include a vital recovery community, an articulate student body, and the Substance Use Disorder Coalition.
Working with these groups and others, in the second phase PGP and stakeholders will develop a strategy that builds on what is important to the community. For instance, in Trenton, N.J., where they helped create an antismoking campaign, they learned that youth were tired of hearing about how terrible Trenton was. Teenagers responded positively to the idea that people who grew up in Trenton were tough, proud survivors. PGP worked with youth leaders and individuals whom teens followed on social media to design and implement a campaign that was positive and reflected people’s true experiences. Interestingly, Dr. Smyser told me that they were more likely to turn to kids who were smokers than the class valedictorian or football captain to spearhead the effort. As a result, their inspiring ads and postings look more like the work of young people than the output of Madison Avenue, which speaks more successfully to youth. “If there is a high-risk 16-year-old, the materials need to speak to him or her, not to a teacher or police officer,” says Dr. Smyser.
In the third phase, the campaign will be activated. With the help of stakeholders, PGP provides relevant, creative health content that is meant to be shared through local channels. Put another way, PGP’s campaigns meet people where they’re already spending their time, rather than attempting to get them to go someplace else. As PGP points out, “Health is personal. People listen to their peers and loved ones more than traditional health authorities.” On Martha’s Vineyard, when there is an overdose or a moped accident, we all know about it before the papers come out. We listen and talk to one another on our Island. Another interesting distinction of PGP’s work is that it employs local campaign managers. Rather than running a campaign from a far-away marketing office, PGP hires a person from the community it is serving, and that individual manages the day-to-day work of coalition building and coordinating volunteers. As a public health expert I know once said, “All healthcare is local.”
The fourth phase will focus on evaluating the impact of the interventions. The tools that will measure the impact will be determined as the research phase unfolds. DUI arrests, ER visits, overdose deaths, and the “Youth Risk Behavior Survey” are possible measurement indicators, but other markers might also be significant. One study suggests that youth who eat dinner every night with their family are far less likely to develop substance use problems.
The fourth phase is particularly important for two reasons. First, evaluating the interventions on an ongoing basis will allow for modifying them for greater impact. Second, if successful, this project has implications far beyond the shores of Martha’s Vineyard.
According to Dr. Smyser, if we could demonstrate that we can influence a community’s attitudes and behavior regarding substances, “it would be huge. There are plenty of studies of one-on-one clinical interventions, and some studies of the impact of public health campaigns around particular issues like smoking, but demonstrating the power of a community-led public health campaign on substance use attitudes and behaviors in general would be unique and relevant to communities everywhere. Everyone in public health, from the federal to the state to the local level, would be extremely interested.” Where better to carry out such a study than such a well-defined community as an island?
The public health campaign focused on changing our alcohol and drug use culture fills a gap and is complementary to existing prevention efforts on the Island. It fits with the Island Wide Youth Task Force work to change environmental conditions, i.e server training, ID checks, and parent education; it fits with the Island school departments’ education efforts, and is one of the major recommendations in the recent MedStar report; It fits with the Island Wide Youth Collaborative and their efforts aimed at early intervention; and it fits with the track record established by others on the SUD Coalition, like local law enforcement, Vineyard House, the YMCA and Alex’s Place, Martha’s Vineyard Hospital, and others — we may just be an ideal public health laboratory.
The idea of using Martha’s Vineyard as a public health laboratory has been kicked around for decades. We are a defined population. We have the ability to measure the impact of interventions in a small community. We have multiple supportive institutions that are interested in public health. We are already in the national spotlight, and we have a community that supports new ideas. Furthermore, given our increasingly permissive national culture, the high rates of local alcohol and drug use, and the resulting sickness and death on the Vineyard, there is an immediate need for change.
Martha’s Vineyard Community Services has agreed to be the fiscal sponsor to oversee the contract with PGP. Now all we have to do is raise the funds to get started.
Dr. Charles Silberstein is a psychiatrist at Martha’s Vineyard Hospital and Island Counseling Center. He is board-certified in general, addiction, and geriatric psychiatry. He writes regularly about issues Islanders have with mental health.