What seatbelts, smoking and drunk driving teaches us about COVID-19

Quoting statistics and scolding people won't get them to wear masks or social distance.

Getty Images
Getty Images

This has happened before: Millions of Americans opt to take mortal risks despite clear evidence they are putting themselves and others in danger. Think drunk driving in the 1970s, seat belts in the '80s, and smoking in the '90s.

People knew what was right. They just didn't do it until the public health field adopted a marketing mindset. Clear rules are important but they are insufficient to change behavior.

We can't simply create awareness. Motivating people to act requires real marketing and includes elements like showing and encouraging positive behavior versus using negative scare tactics that we know don't work. It means building campaigns that speak to what people care about versus relying on facts and figures that people ignore.

How do we know this? Because we've done it before.

Wearing masks today is like driving sober in the 1970s. We know it's safer, but we also want to let it slide. Yes, in the 70s we had drunk driving laws. But we also expected drunk driving accidents to continue much like we expect hurricanes and tornadoes to keep occurring.

Mothers Against Drunk Driving toppled those norms and changed our expectations. Eventually, we held drivers, bars, judges and politicians accountable. And we also offered drinkers logistical help in the form of the designated driver.

You can go without a mask and perhaps no one will get sick, just like it's possible to drive drunk without killing anyone. But today if you tell someone you drove drunk (or worse if you crashed your car) it's very unlikely you'll find a friendly ear or a forgiving judge. Driving drunk is no longer acceptable.

When it comes to masks, we've moved closer to that approach with stores like Walmart sending signals about what is socially acceptable — something humans are very attuned to — by requiring masks for entry. But we also need solutions on the logistics front.

We need to find a way to satisfy the human need to gather safely in-person mask-free, just as we allowed people to drink safely together by having designated drivers.

Maybe clearer guidelines on ventilation, outdoor mask use and better testing would help. Just like with drinking, the goal should be to reduce the risk as much as possible. We should not try to enforce a blanket rule people will inevitably ignore.

Social distancing is a buzzkill in the same way warnings about smoking were to young people. In the 1990s teen smoking was skyrocketing. But the turnaround came after public health advocates realized they needed more than just a health message.

Smoking was a symbol of rebellion and control; traits that appeal to adolescents. The youth-oriented 'Truth' campaign, unveiled in 1998, countered by offering teens rebellion against the tobacco industry. Truth wasn't adult oppression. It was teenage fun.

Social distancing will never be fun except for maybe hermits and monks. But physical distancing should not mean abandoning social interactions.

Nowhere is this more true than with young people. Susan Middlestadt of Indiana University and Chris Owens at Northwestern University have been looking at what differentiates people who follow public health recommendations from people who do not. A major factor is ease. Can people distance without upending their life?

People's confidence in their ability to retain social connections and normalcy is critical and we seem to ignore that. Everything from the term 'social distancing' to our inability to promote social closeness with physical distancing is working against us. As with youth smoking, a new perspective on how to frame and institute distancing efforts would help the practice become more widely adopted.

Immunizations are more important than ever, and we're not just talking about the COVID-19. This year the flu shot is critical to prevent a double-whammy of seasonal flu and COVID-19 from overwhelming hospitals. But that doesn't mean people will do it.

Again, risk communication and doctors' recommendations get us only part of the way. Even one of the authors of this essay didn't get a flu shot until his son's hockey club asked. That's the power of norms again: "I'm a hockey coach and hockey coaches get flu shots. Therefore, I'm getting a flu shot."

Add to this the anti-vax movement, the well-meaning but misguided people who do not trust assurances from the CDC and other medical experts that vaccines are safe and necessary. Some people will undoubtedly sit out the regular flu vaccine, as well as any COVID-19 vaccine.

A big part of any public health campaign to make vaccine coverage more universal will be framing. We've learned from our research on fluoridation that ignoring "anti's" because their arguments are not anchored in science is a mistake. Pardon the pun, but public health experts will need to inoculate Americans against the misinformation sure to emerge with any vaccine.

Ventilation matters in a pandemic the same way as seat belts matter in a car. Seat belts don't prevent crashes, they reduce the risk of injury and death. Ventilation doesn't eliminate the coronavirus, but it helps keep the virus from finding a new home in your eyes, nose or mouth.

Japan has worked to prevent COVID-19 transmission in it's famously packed subways in part by requiring the windows to stay cracked open. Uber launched its "Wash Wear Air'" safety campaign to encourage opening a window during each ride.

But how can we apply thinking about ventilation to indoor spaces? Should we be talking about HEPA filters instead of Clorox wipes? Maintaining air flow will become even more important as colder weather sets in this fall and winter, and people spend more time in closed spaces. How can we create a trigger (like cars buzzing when you don't put your seatbelt on) that makes compliance more likely?

Risk messaging and laws only got two-thirds of Americans to wear seat belts. More recent gains came from a twin messaging and law enforcement effort known as "Click It or Ticket." People can easily dismiss the chance of getting in a crash. But that's harder to do with a ticket. Maybe there is a messaging element around the more immediate benefit of fresh air?

To be sure, clear risk communication, along with rules and enforcement are helpful tools and typically drive the first gains in any major shift in public behavior. But they never get you all the way there. In America, if you really want people to change, you have to market the behavior to them.

We've learned this again and again in public health. Let's learn it a little quicker this time.

Peter Mitchell is chief creative officer Marketing for Change and was the first director of the 'Truth' anti-smoking campaign in the late 1990s. Sara Isaac, Marketing for Change's director of strategy and planning, and Mallory Peak, a senior account director at DH, also contributed to this piece.

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