This ad depicts a true story. It begins: A young man walks around his car, which is up on a jack. He says in voice-over: “I got some Oxy after I hurt my neck. First I took them to feel better. Then I kept taking them. I didn’t know they’d be this addictive. I didn’t know how far I’d go to get more.”
Here’s how far he’d go: He lies down under the car. Then he kicks out the jack.
You see the car fall, hear a crunch. “Joe S. from Maine broke his back to get more prescription opioids,” the screen says. And then a voice-over: “Opioid dependence can happen after just five days. Know the truth, spread the truth.”
A similar ad shows a woman taking off her seatbelt and deliberately crashing her car. In another, a man breaks his hand with a hammer. In another, a man slams his arm in a door. Together, those comprised the first national ad campaign in America aimed at preventing opioid misuse.
They came from the Truth Initiative, the organization that was behind truth ads that helped bring about one of the most important public health victories in American history: In 1996, 34 percent of high school seniors had smoked a cigarette in the previous month — the same as in 1975. But by 2019, less than 6 percent smoked.
Can the strategy work again? Let’s look at what the group did right in its antismoking campaign.
Before the truth ads, antismoking ads for teenagers were created by public health experts who, not surprisingly, emphasized that cigarettes can kill you.
That threat works well to encourage adults to quit smoking. But it doesn’t prevent teens from starting. For many adolescents, the danger is a lure; they smoke to rebel against preachy adults. To them, the consequences are decades away, and teens are immortal.
In the 1990s, Florida and California hired advertising agencies that didn’t know about public health, but did know about selling to teens. They created ads to redirect teenage rebellion against the manipulations of the tobacco industry. Some examples:
One California advertisement portrayed tobacco executives in a smoke-filled room, cackling maniacally as they plot to replace 1,100 customers who quit smoking every day — “Actually, technically, they die,” one says.
In Florida, teenagers created ads for a campaign they named “truth.” One showed girls making prank phone calls to tobacco ad executives. “What is the lucky part about Lucky Strike cigarettes?” a girl asks. “It is because” (pause) I might live?”
That was in 1998. Over the next two years, teen smoking in Florida fell by 17.5 percent.
Florida was one of the first states to sue tobacco companies. When a nationwide settlement was reached, part of the money created a national truth campaign. It copied Florida’s strategies and hired its people. And it enjoyed the same success.
Of course, truth ads were only one part of this victory. States and cities raised their cigarette taxes. Indoor smoking vanished. But the ads were crucial.
(This success is now threatened by an explosion in vaping — also known as “juuling,” after the biggest brand, Juul, whose use among teenagers and young adults doubled from 2018 to 2019. Young people who vape are four times more likely to try cigarettes than those who don’t. Counting vaping, teen tobacco use now is the highest it has been in decades.)
Those truth ads still target adolescent smoking. New teenagers are minted every year, so the campaign never ends. It also makes “Ditch Juul” ads that show teens creatively demolishing their vaping equipment.
All this is useful for anti-opioid campaigns. “There’s a lot of crossover in terms of strategy for reaching your target audience of youth,” said Matthew Farrelly, senior director of the Center for Health Policy Science and Tobacco Research at RTI International in North Carolina. “The variety of tactics for getting in front of teens is nearly identical.”
Surveys about the truth ads show that 80 percent of teenagers recognize the brand. And the organization knows what works. A review of published studies in 2014 concluded, “Youth are more likely to recall and think about advertising that includes personal testimonials; a surprising narrative; and intense images, sound and editing.” That’s Joe S. from Maine, all right.
Anti-opioid ads can use the antismoking template, but the message must be different. “Nobody needs education on the fact that tobacco is really bad for you,” said Robin Koval, president and chief executive of the Truth Initiative. “With opioids, we found out how little people know.”
Adolescents know about the misery of addiction — and addiction and overdose at 20 are scary in a way lung cancer at 60 is not. “But there is a lack of understanding and awareness of how easily you can become addicted,” Ms. Koval said.
Some adolescents start using opioids because their friends share. For others, the beginning is pain medication. Getting a prescription in high school after knee surgery or wisdom teeth removal is associated with a 33 percent higher chance of misusing opioids later in life.
A study published by the Centers for Disease Control and Prevention concluded, “The probability of long-term opioid use increases sharply in the first days of therapy” — with a spike after five days. So every truth ad ends with: “Opioid dependence can happen after just five days.”
“The hardest thing to go up against is nobody believes they’re going to become addicted to opioids,” Ms. Koval said. “We had to reverse this notion of otherness. And we have to combat the stigma that says: This is a moral failing and therefore I can’t believe it would happen to me or anybody we know.”
The Joe S. ad is part of a campaign that began in July 2018, in collaboration with the White House Office of National Drug Control Policy and the Ad Council. Facebook, Google, Turner, Amazon and Vice donated advertising time or space. (The Google News Initiative is a funder of the Solutions Journalism Network, my employer.)
Last year, a truth video titled “Treatment Box: Rebekkah’s Story,” won an Emmy. In it, Rebekkah, then 26, started using opioids at 14 after a cheerleading injury. The ad showed her detoxing — minute by minute. The video was projected into a clear glass bedroom-size box in Times Square. Passers-by watched Rebekkah’s pain.
A new ad series, “Best Day,” has a relatable “it could be you” message, said Margie Skeer, associate professor at Tufts University School of Medicine. It’s graduation day, or signing day for college sports, or a basketball awards assembly — but the happy teens explain that on this, their best day, they see their futures as bleak: that the pain of adult stress or a sports injury will lead them to opioids, then addiction, and finally to overdosing. “My mom will bury me with my cleats,” one girl says.
It’s too soon to know if these ads reduce youth opioid misuse. A test of the Joe S.-style ads found that people who saw them were significantly more likely to agree that someone like them could become dependent on prescription opioids.
“It’s maybe not quite as elaborate and creative and multifaceted as the truth campaign,” said Dr. Farrelly. “But if their goal is to raise awareness of risk, it might not be a bad strategy.”
But that’s not the same as avoiding addiction. The gripping Joe S. ads produce horror and fear. “Fear works in the moment,” Dr. Skeer said. “But when people are scared but don’t know what to do next, it can become paralyzing.” Other public health researchers also said that the ads needed to answer the question: “O.K., so what should I do?”
The truth campaign responded that opioids were complicated, and that covering various scenarios in the ad would have been confusing. Instead, it seeks to drive young people to the Truth Initiative website, where they can get advice. The first ads should have a clear focus on “telling stories that felt authentic and true in the voices of young people,” Ms. Koval said. “Helping them to understand this can happen to you.”
Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times, a vice president of the Solutions Journalism Network, and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”
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